
Ci)EmiGHT DEPOSm 



EDUCATIONAL HYGIENE 



ESSENTIALS OF 
EDUCATIONAL HYGIENE 



EDITED BY 

LOUIS W. RAPEER 

PRESIDENT, FEDERATION FOR AMERICAN CHILDHOOD 

DIRECTOR, NATIONAL SCHOOL OF SOCIAL RESEARCH 

WASHINGTON, D. C. 



CHARLES SCRIBNER'S SONS 

NEW YORK CHICAGO BOSTON 



^' 



0' 



V"<<^ 



■b 



A 






Copyright, 1915, 1919, by 
CHARLES SCRIBNER'S SONS 



AUG 25 1919 




/Sis ^. « rr <> rs O /I >7 



PREFACE 

The remarkable movement for the improvement of school 
and community health in the last decade has brought the school 
into such close and intimate relationship with the health work, 
of the home and the community that ^^ school hygiene" is 
hardly broad enough as a term to include the various health 
aspects of the bringing up of children. On the other hand, 
the term ^^ child hygiene" is too broad. The title ^'Educa- 
tional Hygiene" has been adopted for the science and art of 
health preservation and promotion which the school can more 
or less directly promote through its various health agencies. 
When the school nurse visits the homes and improves the 
health of the children below school age as well as that of the 
pupils of the school, and when school physicians provide for 
consultation hours for mothers, whether patrons or not, the 
old-time school hygiene is broadening out into educational 
hygiene. This movement has but begun, and will inevitably 
continue to expand. 

Educational hygiene, furthermore, is desirable as a term, 
since the subject is now taking its place in professional schools 
for the training of teachers as correlative with educational 
psychology, educational sociology, educational philosophy, 
educational history, educational administration, and the Hke. 
As educational administration was once termed school admin- 
istration, so educational hygiene was once termed school 
hygiene, and the desirability of the change in college courses 
is probably not less for the latter than for the former. 

This comparatively new science is broad in scope, cover- 
ing as it does the five divisions : medical supervision, physical 
education, school sanitation, the teaching of hygiene, and the 
hygiene of instruction. Obviously, very few persons can 



Vi PREEACE 

make any just claims to being experts in this entire field, and 
exceedingly few persons have had very much practical and 
scientific experience in all of them. 

This volume is an attempt to bring together in organized 
form the latest information and advice of leading speciahsts 
in all the large phases of the subject. The hygiene of chil- 
dren from the standpoint of the school in its relationship to 
the home and community, from the pre-school period up 
to the college, is sketched in such detail as is possible in so 
comprehensive a volume. There has been a constant temp- 
tation to add chapters on many new phases of the school- 
health movement, but the editor has tried to limit himself 
to certain '' minimum essentials," and to give references to 
the voluminous Hterature which treats at length the many 
topics discussed here only briefly. Each chapter and parts 
of many chapters easily furnish topics for much-needed books, 
some of which have already been provided by contributors 
to the volume. Effort has been made to lead the reader 
on from these condensed statements to the monographic 
literature. 

The school as a public agency ministering to the dominant 
needs of the community in the interests of the state is always 
kept in mind. Each contributor has attempted to show how 
the public educational agencies may improve their assistance 
to the solution of the grave problems of national health and 
vitaHty. Several chapters are comparatively unique in this 
respect, such, for example, as those on public co-operation 
for school-health progress. These give a point of view much 
needed by the' many educators who have neglected educa- 
tional sociology in their professional studies. A chapter on 
the health of the teacher was planned, but omitted because 
the matter, though of great importance, has received little 
scientific study, and because each teacher should have access 
to the little book published on this subject by Professor 
Terman. 

To the many persons who have so kindly lent their assist- 



PREFACE Vll 

ance in contributing to the volume, to his wife, to those who 
have furnished photographs from many parts of the world, 
and to the pubhshers for their cheerful co-operation, the 
editor is sincerely grateful. 

L. W. R. 

Washington, D. C. 



CONTENTS 



PART ONE 
Health Sociology 

CHAPTER PAGE 

I. Public Health and the Public Schools . . i 

By Louis W. Rapeer, M.A., Ph.D., President, Federa- 
tion for American Childhood; Director, National 
School of Social Research, Washington, D. C. 

II. The Public-Health Movement 22 

By E. H. Lewenski-Corwin, Ph.D., Secretary Health 
Committee of the New York City Academy of Medi- 
cine. 



III. Health and Heredity 45 

By Chas. B. Davenport, Ph.D., Carnegie Institution, 
Cold Spring Harbor, Long Island, N. Y. 

IV. The Home Hygiene of Children 59 

By Ernest B. Hoag, A.M., M.D., Supervisor of Edu- 
cational Hygiene, Pasadena, California, and Lecturer 
in Leland Stanford, Jr., University. 

V. Public Co - operation for School - Health 

Agencies 82 

By Clarence A. Perry, A.B., Director of Division of 
Recreation, Russell Sage Foundation. 

VI. The Social Centre and Educational Hygiene . 103 

By Edward J. Ward, A.M., Specialist in Community 
Organization, U. S. Bureau of Education, Washing- 
ton, D. C. 

ix 



CONTENTS 



PART TWO 

The Administration op Educational Hygiene 

CHAPTER PAGE 

VII. The Initiation of a System of Educational 

Hygiene in a School System no 

By the Editor. 

VIII. The General Administration of Educational 

Hygiene 127 

By the Editor. 

IX. A Plan of State Co-operation for School- 
Health Progress 147 

By Geo. A. Mirick, A.M., formerly Assistant State 
Commissioner of Education of New Jersey. 

X. Rural School-Health Administration . . . 153 

By W. I. Larson, S.B., State Inspector of Rural Schools, 
Madison, Wisconsin. 



PART THREE 

The Divisions and Practice of Educational Hygiene 

I. medical supervision of schools 

XL The Standardization of the School Medical 

Service 171 

By the Editor. 

XII. The School Nurse and Her Work .... 204 

By LiNA Rogers Struthers, R.N., First Municipal 
School Nurse of America, recently Supervisor of 
School Nurses, Toronto, Canada. 



CONTENTS 



XI 



PAGE 



XIII. School Feeding .217 

By Louise Stevens Bryant, Ph.D., Lecturer on Psy- 
chology at the Pennsylvania School for Social Service, 
Philadelphia; formerly Assistant in the Psychological 
Clinic, University of Pennsylvania. 



XIV. Open-Air and Open- Window Schools .... 

By S. C. KiNGSLEY, A.M., Director, Welfare Federation, 
Cleveland, Ohio. 



238 



II. SCHOOL SANITATION 



XV. Rural School Sanitation 255 

By A. C. MoNAHAN, B.S., Rural School Specialisil, U. S. 
Bureau of Education. 



XVI. Hygienic School Environment 280 

By L. N. HiNES, A.M., State Superintendent of Public 
Instruction; Editor of the Educator Journal, Indian- 
apolis, Indiana. 



XVII. School Sanitation Standards 

By the Editor. 



298 



ni. the hygiene or instruction 



The General Hygiene of Instruction . . . 

By Arthur K. Beik, Ph.D., Professor of Psychology 
and Hygiene, New York State College for Teachers, 
Albany, New York. 



323 



XIX. The Hygiene of School Subjects 
By Arthur K. Beik, Ph.D. 



342 



XU CONTENTS 

IV. THE TEACHING OF HYGIENE 

CHAPTER PAGE 

XX. The Teaching of Hygiene in Elementary 

Schools 358 

By J. Mace Andress, Ph.D., Head of the Department 
of Psychology and Child Study, Boston Normal School, 
Boston, Massachusetts. 

XXI. Health Teaching in High Schools .... 380 

By W. S. Small, Ph.D., Specialist in School Hygiene 
and Sanitation, U. S. Bureau of Education, Washing- 
ton, D. C. 

XXII. Industrial Hygiene and Vocational Education 404 

By the Editor. 

XXIII. Sex Hyglene and Sex Education 413 

By Ira S. Wile, M.S., M.D., Editor Medical Review of 
Reviews; Lecturer in the New York University School 
of Pedagogy. 

XXrV. Play and Recreation at the Rural School . 433 

By S. H. Curtis, Ph.D., Lecturer on Public Recreation, 
Olivet, Michigan; formerly Secretary of the Play- 
ground Association of America. 



EDUCATIONAL HYGIENE 

PART I 

HEALTH SOCIOLOGY 

CHAPTER I 

PUBLIC HEALTH AND THE PUBLIC SCHOOLS 

The Public-Health Problem. — In a recent volume Price 
Collier has asserted that "the earth will be as cold as the 
moon before all men reahze that the only neal wealth is 
health"; 1 and certainly the experiences of the past seem to 
warrant his conclusion. Health is and will always remain a 
fundamental value of life, practically inseparable from life 
itself. Yet on every side, the world over, we are confronted 
by the fact that health, including normal physical develop- 
ment, longevity, and splendid bodily resistance, is being 
only very inadequately achieved by millions of people. 
When a third of all the children born with such cost into a 
civilized community like America die before the age of five, 
when the draft disclosed that more than one-third of the 
flower of America's manhood was physically unfit for mili- 
tary service, when the average term of life of our people is 
some twenty years shorter than it should be, and when ill- 
ness, deformities, and multifarious physical defects are afflict- 
ing the race with an immense and overburdening cost, it 
would seem that every agency which the state has at its dis- 
posal would be vigorously engaged in preventing and eliminat- 
ing from the world, or lessening to a fraction of their present 
destructiveness, these enemies of health and vitality. 
^ "Germany and the Germans" (Scribners). 



2 EDUCATIONAL HYGIENE 

Instead of such universal and united resistance to a 
common foe, what do we find ? In the first place, we find a 
great private medical profession that lives by the diagnosis 
and cure of existing ailments, but not primarily by their pre- 
vention and final ehmination from the world. Outside of 
China disease has long been the friend, not the enemy, of 
physicians, for it has been disease that has brought to them 
their livelihood. To slay the food-bringer has not been the 
poHcy of the past, and it is one of the greatest glories of the 
present that an increasing number of physicians are becom- 
ing willing to make such sacrifice. Unfortunately, the social 
situation has demanded the wrong thing. It should be made 
the physician's chief mission and means of liveHhood to ban- 
ish from the earth the enemies of health and physical per- 
fection. 

This Utopian condition is, indeed, coming swiftly upon 
us in the very rapid increase of pubHc agencies manned by 
doctors and nurses in great numbers. Such pubKc hygienists 
as Winslow prophesy, indeed, the complete or almost complete 
sociaHzation of health service in the next few decades.^ Great 
insurance societies are finding it to their advantage to keep 
their policy-holders well by periodical examinations, health 
instruction, nipping incipient ailments, and by sending visit- 
ing nurses to those who need their help. Our governmental 
health service, in the form of local, State, and national health 
departments or bureaus, has a far greater motive for disease 
prevention, but it is in general, though with many brilliant 
exceptions, exceedingly inadequate and inefficient. These 
bureaus, however, are everywhere so increasing their staffs 
that preventive medicine is really making fairly rapid progress. 
Many agencies, more or less efficient, are steadily tending to 
make the work of the old-time curative-medicine doctor less 
necessary, and in many places the clash between the factors 

1 "Efficiency in the Public-Health Campaign," in the North American Re- 
view, June, 1913. A free bulletin of the New York State Board of Health, 
Albany. 



PUBLIC HEALTH AND THE PUBLIC SCHOOLS 3 

for eliminating the causes of disease and for treating disease 
after it has come into being is not as mild as, to the outsider, 
it may appear. The inevitable movement will be to push the 
curative doctor over into the field that for the time being 
cannot, by the best efforts, both pubHc and private, be con- 
quered by preventive measures, including hygiene, sanita- 
tion, physical development, etc. 

Because of the comparative lack of development of pre- 
ventive medicine and public-health agencies, we see, in the 
second place, more clearly than ever before, a great host of 
only partially utilized agencies for reducing or eliminating our 
disgraceful and enormous death, illness, and physical-defects 
losses. Fundamentally, of course, the elimination of un- 
necessary ill health depends upon the two factors of nature 
and nurture, of eugenics and hygiene. Doctor Davenport 
shows briefly in a later chapter the considerab^ and largely 
unguessed-at influence of heredity upon the amount of disease 
and physical defects among human beings. Ideally, of course, 
we should all be the offspring of physically and mentally per- 
fect parents. This would be our greatest insurance for the 
possession of Hke characteristics. To help in some measure 
to bring about such a happy state, to eHminate many of our 
most terrible losses in the way of feeble-mindedness and gross 
physical imperfections that are inheritable, and to give sound 
biological advice to the hygienist working with environment, in 
order that he may prevent the bringing out of native weak- 
nesses — these are the objects of many eugenic agencies now 
springing rapidly into being. 

Public-Health Agencies. — Certain factors in heredity are, 
then, of utmost importance to the hygienist, but his chief 
work falls in the field of nurture, of environmental control.^ 
It is the duty of the state to insure, within reasonable Hmits, 
that its children and future citizens be well born; but the 
duty which is far clearer and simpler at present is that of 
providing such environmental control of the population, young 

1 See Winslow, "Man and the Microbe," Popular Science Monthly, July, 1914- 



4 EDUCATIONAL HYGIENE 

and old, that disease, premature death, and physical defects 
may be reduced to a minimum. The public agencies for such 
health-control may be briefly and tentatively classified as 
follows : 

1. Medical or health supervision of the population. 

2. Securing in all ways a sanitary environment. 

3. Medical or health research. 

4. Educational control of the population. 

Since this is a free country, where very much depends 
upon the choice of the people, the last-mentioned means, 
educational control of the population, far outweighs in im- 
portance all the others. Every agency of health amehoration 
soon discovers and heralds abroad that the progress of health 
measures depends absolutely and finally upon the education 
of the people, old and young. If laws for health improvement 
are to be enacted, they must have the support of an enlight- 
ened public both before and after they are passed; if health 
measures are to be practised they must through some form of 
educational effort be made habit. In short, the most funda- 
mental means of health improvement is through education 
in the habits, knowledge, ideals, and the physical develop- 
ment which go with socially efficient right living, personal and 
public. Such education begins at birth and lasts throughout 
life. It can only be partially monopolized by the public 
educational, or schooling, system. And yet, since the educa- 
tional system is extending its beneficent influence over those 
of pre-school and post-school age, and, moreover, since it 
influences individuals in their most plastic and formative 
period, that of childhood, the public school stands out easily 
as the greatest single instrument for health promotion pos- 
sessed by the civilized world. 

Educational Hygiene. — In its widest sense, then, edu- 
cational hygiene is broader than the school, including, as it 
does, all agencies for the promotion of health measures 
through education. The boards of health, the newspapers 
and magazines, the public lecturers of the American Medical 



PUBLIC HEALTH AND THE PUBLIC SCHOOLS 5 

Association, the leading insurance companies, the anti- 
tuberculosis and other societies, and many other agencies^ 
are very largely engaged in the field of educational hygiene. 
In the narrower sense, as used in this volume, educational 
hygiene is the name given to all the phases of health promo- 
tion work which may be and are undertaken by schools, 
especially pubHc schools, from kindergarten through college, 
for people of all ages, but especially for those between the 
ages of four and twenty-four. 

We have for some time had the science of educational 
psychology, used especially in the training of teachers. We 
have also educational sociology, educational administration, 
educational history, etc., and it is high time that we have an 
educational hygiene. The exclusive emphasis upon educa- 
tional psychology in the past has led to a lop-sided knowledge 
of the educational process and the nature of children. The 
pathological and physical child is at least as important from 
the state's point of view as is the ignorant and mental child. 
This volume attempts to treat of the health and physical 
well-being of the people, old and young, as it can be affected 
by public schools. The future extensions of the school in this 
direction are beyond prophecy. 

That the school may directly affect the health and normal 
physical development of persons who do not at the time at- 
tend the school as pupils hardly needs demonstration, and will 
be plentifully illustrated in the following pages. When school 
physicians and nurses have consultation hours for mothers 
with babes in arms, when the nurses go day after day into 
the homes to help improve home hygiene, when the schools 
are used as social centres for the health education and recrea- 
tion of the community, when there is health vocational guid- 
ance in and after the school period, when schools use news- 
papers and various civic organizations for the promotion of 

*See Dresslar on "Public Health Teaching Agencies" and "Methods and 
Means of Health Teaching," in the 1912 and 1913 Reports of the U. S. Bureau 
of Education. 



6 EDUCATIONAL HYGIENE 

the health of the children and community, then we have an 
influence that is far broader than the old-time ^'school hy- 
giene/' an influence that may very appropriately go by the 
name of educational hygiene. 

The various phases of this rapidly developing science we 
shall briefly sketch as medical supervision, physical education, 
school sanitation, the teaching of hygiene, and the hygiene of 
methods of teaching and management. 

The National Health Problem. — Before we can say what 
the schools, through the development of educational hygiene, 
can do for the health and happiness of our nation, it is neces- 
sary for us to face the actual health problems of the people 
and nation. The principal problems of the people and nation 
set the principal problems for their pubHc educational sys- 
tems. If the educational systems of the country can be 
helped to concentrate their energies upon the really big 
problems of Kfe instead of upon so many little or obsolete 
ones, their social efficiency can undoubtedly be marvellously 
increased. 

The principal phases of the national health problem are 
shown in the number of preventable deaths, in the prevaiKng 
and preventable amount of illness, or morbidity, and in the 
number and preventabihty of physical defects which lower 
vitality and xeduce working efhciency and happiness. In 
a somewhat careful investigation, pubHshed elsewhere,^ the 
writer has attempted to compute from mortality statistics 
and other sources, by the methods used by Hfe-insurance 
statisticians, the nature and extent of the national and school 
health problem. We can here only briefly summarize our 
relatively inaccurate and tentative findings, in the assurance, 
however, that great as they may seem the results are probably 
not exaggerations. 

Death Losses. — The death losses to our country are enor- 
mous and largely preventable. The judgment of the best 

^ "School Health Administration," published by Teachers College, Columbia 
University, chapters I and II. (Out of print.) 



PUBLIC HEALTH AND THE PUBLIC SCHOOLS 7 

experts versed in mortality statistics and in the results of 
various forms of hygienic improvement here and abroad agree 
pretty well with Professor Fisher's estimates of preventability 
given in his book on "National Vitality."^ His estimate^ 
arrived at with the assistance of thirty experts in health 
matters, is that in general about 42 per cent of the deaths of 
persons in the United States could be reasonably prevented 
or postponed, ^'if knowledge now existing among well-in- 
formed men in the medical profession were actually appKed 
in a reasonable way and to a reasonable extent." An exami- 
nation of his tables showing his estimates of preventability 
for deaths, from the manifold causes, will convince most 
intelligent persons that they are fairly conservative and that 
they are based on present data, counting not at all on the as- 
sured advance in preventive medicine. ^ 

Some of the leading facts relating to this great problem are 
as follows: 

1. One-fifth of all the children born each year in this 
country die before they are a year old, approximately a half- 
million. Where there are fairly efficient and developed 
health agencies, such as boards of health, carefully conducted 
infant-mortahty campaigns in this country have cut this 
death-rate to about one-tenth of these proportions. 

2. Half of the persons born in our country die before they 
are forty years of age, and about half of these before the age 
of five. 

3. The average age of persons dying is gradually rising, 
but is still below the age of forty — near thirty-eight. 

4. Approximately 1,600,000 of our population die each 
year — about 670,000 (42 per cent) of reasonabty preventable 
diseases. The economic losses due to these deaths are at least 
a billion dollars. These losses come in the form of public and 
private care of the sick and dead and in lost wages, but prin- 
cipally in the form of cut-off potential earnings. The value 
of a life at various ages can, in general, be somewhat easily 

^ Also published as a government report. 



8 



EDUCATIONAL HYGIENE 



DEATHS FROM ALL CAUSES IN INDIANA 
All Ages 



1912 



Average for preceding three years 




P^^yy^r Diphtheria and Croup 
y^M^/j^^i Suicides 



\ ^^^^^^^^^^/MM influenza 



w^M^/^i\ Senility 



500 



lOJ'O 



2000 



3000 



4000 



5000 



lUnclassitied 
Causes 



Org'c Heart Disease 
Tuberculosis of the Lungs 
"Acute Nephritis and Brights' Disease 
External Causes (Suicides Excepted) 
Hemorrhage and Softening of the Brain 
Cancer and Other Malignant Tumors 
'Co:ngenital Debility and Malformations 
Pneumonia 

Diarrhoea and Enteritis (urnder two years) 
Other Diseases of the Respiratory System (T..B,. Excepted^ 
Diseases of the Stoma.cii CCancer Excepted) 
wy//y>^.yy/y>/^ Typhoid Fever 



Olher Forms of Tuberculosis 



7777J7? Appendicitis 

S^ Cirrhosis of the Liveir 

^^aOther Epidemic Diseases 



Y'TTTn Intestinal Obstruction 

f777^ Whooping Cough 

7zz^ AciLte Bronchitis 

mm Cliranic BronchiTis 

7777^ Puerpenal Septicemia 

^S OtTier Puerperal Accidents of Pregnancy and Laljar 

y7777\ Tuberculosis Meflinoitis 

^zm Nod Canferous Turm:or & other diseases of the female genltsd oj^ans 

^ Scarlel Fever 

* Meflar'ra 

I3 Simple -Meiilngilis 

Hernia 
^TTTTn Measles 
aPofiorayelilisCAcute Anterior) 
3 Cerebro spinal fever 
3 Unknown orill defined diseases 

Cholera Nostras 

Smallpox 



PUBLIC HEALTH AND THE PUBLIC SCHOOLS 9 

computed, and the average value for all ages used by econo- 
mists is $1,700. 

The table on pages 10 and 11, taken from *^ School Health 
Administration,'' shows in some detail a condensation of the 
1910 mortality statistics made by the author, and shows also 
the deaths of children of school age and the age groups of 
most deaths. The registration area is composed of those 
States and cities sensitive enough to their health needs to 
enforce reasonable registration of deaths. It reaches about 
three-fifths of the population.^ 

Those who wish to study educational hygiene in relation 
to national and community health problems may well ex- 
amine the following table. A very desirable addition to 
such study would be (i) to get a free copy of the latest 
Mortality Statistics from the United States Census Bureau, 
and (2) to get the local reports of the boards ^f health of the 
community and State. Any careful study of such data will 
immediately raise in the mind of an intelligent and socially 
minded student and health worker the national and school- 
health problem. What can we do to prevent these terrible 
and largely unnecessary losses? 

Illness and Physical-Defects Losses.— According to the 
best obtainable data, about 3,000,000 persons in the United 
States are constantly seriously ill. Their illness causes loss 
of wages to a computable number, lowered vitality, and fre- 
quently death. These illnesses, largely and increasingly pre- 
ventable, cause further enormous economic losses not computed 
under deaths, which I have estimated, using Professor Fisher's 
and insurance methods, as about another billion dollars an- 
nually. The losses in happiness, the evil effects of breaking 
up homes, and all such losses of a personal, human, and 
psychological character are, of course, beyond computation. 
From these serious illnesses and the additional physical de- 
fects and minor illnesses comes more or less directly a large 
portion of the most serious blots upon civilization, such as 
* 1910 U. S. Mortality Statistics. 



lO 



EDUCATIONAL HYGIENE 



TABLE I 
Causes of Death for the Registration Area, 1910 * 



All Causes. 



I. General diseases 

1. Typhoid fever 

2. Malaria 

3. Smallpox 

4. Measles 

5. Scarlet fever 

6. Whooping cough 

7. Diphtheria and croup 

8. Influenza 

9. Cholera nostras 

10. Dysentery 

II. Erysipelas 

12. Other epidemic diseases. . 

13. Purulent infection, etc... 

14. Rabies 

15. Tetanus 

16. Pellagra 

17. Tuberculosis (of lungs) . . . 

Tuberculosis (other) 

Rickets 

Syphilis 

Gonococcus infection 

2 2 . Cancer and other m. tumors 
23. Other tumors 

Acute articular rheumatism 

Diabetes 

Leuchemia 

Anemia, chlorosis 

Other general diseases 



i». 
19. 
20. 
21 



24. 

25- 

26. 
27. 
28. 



AU 
ages 



II. 

29. 
30. 
31- 
32. 
33- 
34- 
35- 
36. 
37- 
38. 

III. 

3t)- 
40. 
41. 
42. 

43- 

44. 



Nervous sys. — special sense. 

Encephalitis 

Meningitis 

Spinal cord, other dis 

Apoplexy, cereb. hem 

Paralysis, without sp. cause 

Epilepsy 

Convulsions (nonpuerperal) 
Chorea, St. Vitus' s dance . . 
Nervous system, other d. . . 
Ear diseases 



Circulatory system 

Pericarditis 

Endocarditis, acute 

Organic d. of the heart 

Angina pectoris 

Embolism and thrombosis . 
Lymphatic system, dis . . . . 



805,412 

215,692 

12,673 
1. 167 
202 
6,598 
6,25s 
6,146 

11,521 

7,774 

536 
3,446 
2,442 

198 

1,877 

64 

1,373 

368 
73,214 
13,09s 

455 
3,221 

197 
41,039 

553 
3,328 
8,040 

864 
2,614 
5,014 

77,991 

761 
7,619 
4,101 
39,701 
7,756 
2,287 

200 

123 
2,069 

967 

100,106 

650 

4>792 

76,178 

3,869 

1,990 

255 



CHILDREN OF SCHOOL AGES 



5-9 



17,943 

8,891 

684 
58 

6 
588 

1,731 
228 

2,938 
122 

14 

47 

8 

23 

73 

13 

162 

4 

489 

933 

13 

24 

83 
9 

327 
144 

44 

39 

4 

1,368 

34 
683 
264 

47 
27 

79 
54 
13 
70 
92 

999 

32 
203 
716 

7 
20 

14 



10-14 



11,736 

4,978 

854 

40 

6 

152 

442 

17 
700 

73 

8 

15 

14 

II 

62 

9 

153 

5 

1,048 

586 

8 

II 

I 

76 

4 

357 

206 

35 
40 
10 

889 

37 
365 
146 

46 

21 

118 

9 

18 
58 
64 

1,319 

32 

226 

1,011 

12 

19 



IS-19 



19,772 

9,770 

1,681 

67 

17 

112 

232 

10 

228 

119 

7 

13 

35 

3 

86 

6 

88 

12 

5,166 

933 

4 

36 

17 

152 

6 

261 

258 

39 

70 

67 

976 

39 
294 
130 
103 

29 
172 
18 
41 
63 
46 

1,447 

14 
196 

1,158 

17 

33 

9 



Total 
5-14 



29,679 

13,869 

1,537 

98 

12 

740 

2,173 

245 

3,638 

195 

22 

62 

22 

34 

135 

22 

315 

9 

1,537 

1,519 

21 

35 

I 

3 
13 
684 
350 
79 
79 
14 

2,257 

71 
1,048 

410 
93 
48 

197 
63 
31 

128 

156 

2,318 

64 

429 

1,727 

19 
39 

23 



Age 
group 
of most 
deaths 



25-29 

20-24 
20-24 

0- I 

1- 2 

5- 9 
o- I 

5- 9 

70-74 

o- I 

O- I 
O- I 

o- I 

O- I 

5- 9 

O- I 

30-34 
25-29 
20-34 

o- I 

o- I 

o- I 

60-64 

65-74 

10-14 
60-64 

40-55 

60-64 

O- I 

70-74 

O- I 
O- I 

65-69 
70-74 
70-74 
25-29 

5- 9 

15-19 

50-54 

Under i 

65-69 

65-69 
55-59 
70-74 
65-69 

65-69 
o- I 



1 Condensed from the table giving 189 different causes. The registration area is 
slowly enlarging, but in this year included only about three-fifths of the population. 
In many of the registration States the returns are inaccurate, and somewhat incomplete 
("at least 90 per cent of the total"). We are far behind most European countries in 
records of both deaths and births. 



PUBLIC HEALTH AND THE PUBLIC SCHOOLS 



II 



TABLE 1— Continued 
Causes of Death for the Registration Area, 1910 



IV. Respiratory system 

45. Nasal fossae disease 

46. Larynx, dis. of 

47. Bronchitis, acute 

48. Bronchitis, chronic 

49. Bronchopneumonia 

50. Pneumonia 

51. Pleurisy 

52. Pulmonary cong't'n, p. ap. . 

53. Other d. of rasp, system 

V. Digestive system 

54. Mouth and annexa, d 

55. Pharynx. 

56. Ulcer of stomach 

57. Other d. of stomach (not c.) 

58. Diarrhea and enteritis 

59. Appendicitis and typhlitis.. 

60. Hernia 

61. Intestinal obstruction 

62. Other diseases of the intest. 

63. Cirrhosis of liver 

64. Other diseases of liver 

65. Peritonitis (nonpuerp.) 

66. Other d. of digestive system 

VI. Genito-urinary sys. nonv 

67. Nephritis, acute 

68. Bright's disease 

69. Kidneys, other d. of 

70. Other d. of uterus 

71. Salpingitis and other f. d.. . 

VII. The puerperal state 

VIII. Shin and cellular tissue .. . 

72. Gangrene 

73. Abscess, acute 

IX. Bones and locomotive organs 

74. Bones, not t. b 

75. Joints, not t. b. or rheum. . . 

X. Malformations 

76. Hydrocephalus 

77. Congen. m. of heart 

XI. Early infancy 

XIL Oldage 

XIII. External causes 

78. Suicide 

79. Accidental or undefined 

XIV. Ill-defined diseases , 





CHILDREN OF SCHOOL AGES 




Age 


AU 








Total 


group 


ages 








5-14 


of most 




S-9 


10-14 


1S-19 




deaths 


100,835 


2,035 


956 


1,517 


299 


0- I 


135 


9 


9 


5 


14 


0- I 


746 


90 


13 


II 


103 


0- I 


7,229 


90 


21 


21 


III 


75-79 


5,391 


62 


30 


36 


92 


75-79 


25»337 


522 


148 


158 


670 


0- I 


54,187 


1,138 


664 


1,140 


1,802 


0- I 


2,150 


66 


32 


83 


98 


60-64 


24,499 


28 


17 


17 


45 


0- I 


1,174 


16 


13 


28 


29 


0- I 


104,801 


1,669 


1,270 


1,429 


2,939 


0- I 


423 


II 


4 


6 


15 


0- I 


840 


123 


51 


40 


174 


5- 9 


2,203 


13 


18 


47 


31 


45-49 


8,403 


116 


57 


73 


173 


0- I 


63,180 


469 


132 


91 


601 


0- I 


6,128 


571 


718 


754 


1,289 


15-18 


2,192 


8 


6 


2^ 


14 


65-69 


4,486 


127 


88 


117 


215 


0- I 


1,571 


25 


20 


22 


45 


0- I 


7,485 


15 


16 


25 


31 


50-54 


3,092 


36 


35 


34 


71 


60-64 


2,419 


132 


109 


162 


241 


20-24 


329 


9 


4 


7 


13 


50-54 


62,559 


509 


447 


■780 


956 


70-74 


5,66s 


253 


165 


199 


418 


40-44 


47,665 


224 


263 


440 


487 


70-74 


1,389 


22 


6 


16 


28 


0- I 


774 


I 


5 


29 


6 


25-29 


1,298 


I 


2 


75 


3 


25-29 


8,455 




II 


620 


11 


25-29 


3,008 


26 


14 


31 


40 


0- I 


1,748 


10 


7 


8 


17 


75-79 


506 


12 


5 


9 


17 


0- I 


1,317 


100 


95 


89 


19s 


0- I 


1,145 


93 


90 


81 


183 


0- I 


119 


6 


4 


5 


10 


35-39 


7,998 


76 


36 


20 


112 


0- I 


685 


30 


II 


4 


41 


0- I 


4,821 


2,2, 


25 


13 


55 


0- I 


39,388 






•• 


•• 


0- 1 


13,604 




•• 


.. 




80-84 


57,196 


2,193 


1,678 


3,024 


3,871 


25-30 


8,590 


I 


31 


326 


32 


35-39 


45,416 


2,161 


1,599 


2,525 


3,760 


20-24 


12,462 


74 


43 


68 


117 


75-79 



GROWTH OF THE REGISTRATION AREA FOR DEATHS, 

1900-1911 

(From U. S. Mortality Statistics, 191 1) 

Up to 1880 only two States, Massachusetts and New Jersey, had registra- 
tion laws. 

1900 




1911 




N.DAK. 



I NEBR. yOVik) 



KANS, 



^\ 



PER CENT OP UNITED STATES 
POPULATION AREA 



-• / N.MEX. f 1 °^*- 1*'"«-/-1"T' 
rd-rS—' tEXAS \,J ( 




V 



\ 




Note. — In addition to the registration States (shaded in the cartograms) , 
the registration area includes thirty-eight cities in non-registration States. No 
accurate data respecting the niimber and causes of death in nearly half our 
country can yet be made. Laws requiring registration are of first importance 
in non-registration States. The registration area for births is very much smaller. 



12 



PUBLIC HEALTH AND THE PUBLIC SCHOOLS 1 3 

alcoholism and poverty. Devine estimates that not less 
than one-fourth of all poverty is directly caused by illness. 
That from tuberculosis, from the best estimates, seems to be 
a very large portion of the whole. The lessening of tubercu- 
losis means the lessening of poverty, and tuberculosis pre- 
vention is very largely an educational problem. A further 
statement of the general problem and the various means of 
solution may be found in the next chapter. 

In brief, then, we see that the problem of health is one of 
the most serious that the country faces. The conservation of 
our natural resources, such as soils, minerals, forests, and 
water-power, is a mere bagatelle compared with the problem 
of the conservation of our human resources. Of these we are 
criminally wasteful. While we are making some headway in 
the control of typhoid, smallpox, tuberculosis^ the diseases 
of infancy, and others, there has arisen in recent years 
an increasing number of degenerative diseases in middle 
life due largely to ignorance of personal hygiene.^ Such 
increases tend to keep the death-rate as high as it has been 
in the past. 

The School Health Problem. — While the reader is passing 
through this chamber of horrors and getting some acquaint- 
ance with a few of the phases of the health problem which 
it is necessary for us resolutely to face if we are to solve it, 
he should obtain some ghmpse of the evil effects of ill health 
upon the schools, their efficiency, their pupils, and their 
teachers. 

The death losses of pupils of school age, whether in school 
or out, are enormous and largely preventable. Undoubtedly 
many of these deaths are and will continue to be inevitable, 
but our success in decreasing the death-rate for many of the 
causes of death in these ages, and many other factors, tends 
to show that the ratio estabHshed by Fisher of about seventy 
per cent of preventabiHty for these ages is not too high. 
iSee Coleman's "The People's Health," p. 228. 



14 



EDUCATIONAL HYGIENE 



TABLE III 

Death-Rates at Various Ages 

"The following table shows the changes in mortality that have occurred 
in the eleven years from 1900 to 191 1 in the group of registration States as con- 
stituted in 1900. This area embraced about one-fourth of the total population 
of the United States in 191 1 and hence the results are of much significance 
as showing the general tendency of mortality for the country as a whole." 



AGE GROUP 


DEATH-RATE ^ PER I, OOO POPUXATION FOR STATES 
INCLUDED EST THE REGISTRATION AREA IN IQOO ^ 


PER CENT DEATH- 
RATE IN igil REP- 
RESENTS OE THAT 


I9II 


1900 


IN 1900* 

■ 


Both 

sexes 


Males 


Fe- 
males 


Both 
sexes 


Males 


Fe- 
males 


Both 
sexes 


Males 


Fe- 
males 


All ages: 

Crude rate 

Corrected rate^ . . 

Under 5 years 

Under i year 

I to 4 years 

5 to 9 years 

10 to 14 years 

15 to 19 years 

20 to 24 years 

25 to 34 years 

35 to 44 years 

45 to 54 years 

55 to 64 years 

65 to 74 years 

75 years and over. . . 


14.9 
14.6 


15.8 
15.3 


14.0 
13.9 


17.2 
17.0 


17.9 
17.6 


16. 5 
16.5 


87 
86 


88 
87 


85 
84 


36.6 

125.5 
12.8 

3.2 
2.2 

3-5 
5.0 

6.3 

9.4 

14.5 

28.4 

58.3 
143.0 


39.8 

138.6 

13.3 

3.4 
2.4 

3.7 
5.3 

6.7 
10.4 
16. 1 

30.9 

61.6 

147.4 


33.3 

112. 1 

12.2 

3-1 
2.1 

3-3 

4.7 

6.0 

• 8.3 
12.9 
26.0 

55.1 
139.2 


49.9 

161. 9 

19.8 

4-7 
3.0 
4.8 
6.8 

8.2 
10.3 
15.0 
27.3 
56.5 
142.4 


54.1 

178.4 

20.4 

4.7 
2.9 

4.9 
7.0 

8.3 
10.8 
15.8 
28.8 
59.5 
145.9 


45.7 

145.0 

19. 1 

4.6 

3.1 
4.8 
6.7 

8.2 

9.8 

14.2 

25.8 

53.7 

139.3 


73 
78 
65 

68 
73 
73 

74 

77 

91 

97 

104 

103 

100 


74 
78 
65 

72 
83 
76 
76 

81 

96 

102 

107 
104 

lOI 


73 
77 
64 

67 
68 
69 
70 

73 
85 
91 

lOI 

103 
100 



iFrom 191 1 U. S. Mortality Statistics. 2 Exclusive of still-births. 

3 Group includes Connecticut, the District of Columbia, Indiana, Maine, Massachu- 
setts, Michigan, New Hampshire, New Jersey, New York, Rhode Island, and Vermont. 

4 The death-rate for 19 11 for both sexes is only 87% of that of 1900 and the death- 
rate for males greater, loi to 107%, than in 1900. Notice also that infant mortality 
decreased from 161.9 a thousand to 125.5 a thousand in 1911. 

6 Based on the standard million of England and Wales, 1901. 



Effective health education of pupils and parents, and effect- 
ive public-health service, ought to make possible an almost 
complete extermination of a large number of diseases in these 
hardy age periods from five to twenty.^ 

1 " One interesting and notable thing about modern public-health work is 
its tendency to supplement purely administrative methods by educational 
ones. " — ^WiNSLOW. 



PUBLIC HEALTH AND THE PLTBLIC SCHOOLS 



15 











































joU 




































/ 


" 


HO 








HISTOGRAM ILLUSTRATING 

TABLE II, DEATH RATE 
PER 1,000 POPULATION FOR 
STATES INCLUDED IN 
REGISTRATION AREA 
IN 1900 BOTH SEXES, 1911. 
Rates for school ages:- 
5-9 — 3.2 per 1000 
10-14- 2.2 » « 
15-19— 3.5 " 












/ 


f 




laU 


















/ 






120 
















1 


/ 






110 
















/ 








lOO 
















/ 








90 














1 


1 








oU 








































/U 




































































y 


1 










OU 




























/ 












4U 


























/ 














iJU 
























y 
















Zv 


V 


















,^ 


^ 








% 










Bate 5 


\ 







































Age Groups 


:'0-5 


5-9 


10-14 


15-19 


20-24 


25- 


-34 


35- 


-44 


45- 


-54 


55 


-64 


65 


-74 


74 and 


over 





Note. — ^The rate for both sexes in igii for these ten States is for the infants 
less than a year old 125.5, and for the ages two to four inclusive only 12.8. 
These data do not include still-births. The years ten to fourteen inclusive seem 
to be the hardiest years of life, although the sickness rate is higher than in cer- 
tain other age groups. The number of deaths at the lowest part of the curve 
are as follows: 5-9 — 18,112. 10-14 — 12,337. 15-19 — 21,154. 

There are, however, in the United States approximately 
100,000 children of elementary and high-school age who die 
each year. Probably at least 60,000 of these deaths were 
unnecessary losses (^*. 6., preventable), and 50,000, or half, 
would probably be a low estimate. In looking over the death- 
rates for various diseases in comparison with the number of 
cases of illness in many cities it has been found that the num- 
ber of cases occurring and the proportion of deaths from the 
various ailments vary quite directly with the efhciency of 
the pubHc-health agencies. Efficient health agencies decrease 
the number of cases of illness and the proportion of deaths 
from them. Many city and State boards of health print on 



i6 



EDUCATIONAL HYGIENE 



TABLE III 

Showing the Preventability of Deaths of Children of Elementary 
School Age, 5-14, for 25 Most Numerous Causes of Death, 19 10 



CAUSES OF DEATHS 



No. deaths 
in registra- 
tion area 



Per cent 

pre- 
ventable 



Total No. 
deaths in 
the U. S. 



No. pre- 
ventable 
deaths 



I 
2 
3 
4 
5 
6 

7 
8 
9 
10 
II 
12 
13 
14 
IS 
16 

17 
18 

19 
20 
21 

22 

23 
24 

25 



Accidents 

Diphtheria and croup. . . 

Scarlet fever 

Pneumonia 

Heart, organic disease. . . 

Typhoid fever 

Tuberculosis of lungs 

Tuberculosis, other 

Appendicitis 

Meningitis 

Measles 

Rheumatism, articular. . 

Bronchopneumonia 

Diarrhea and enteritis. . . 
Bright's disease, kidneys. 

Endocarditis, heart 

Nephritis, acute, kidneys 

Spinal cord, others 

Diabetes 

Tetanus, lockjaw 

Whooping-cough 

Peritonitis 

Intestinal obstruction 

Epilepsy 

Influenza, grippe 



3,760 
3,638 

2,173 

1, 802 

1,727 

1,537 

1,537 

1,519 

1,218 

1,048 

740 

684 

670 

601 

487 

429 

418 

410 

350 

315 

245 

241 

215 

197 
195 



70 
50 
45 
25 
85 
75 
75 
50 
70 
40 
10 
50 
60 
40 
25 
30 

10 
80 
40 
55 
25 

50 



6,300 

6,200 

3,700 

3,050 

3,000 

2,600 

2,600 

2,560 

2,160 

1,600 

1,250 

1,150 

1,140 

1,020 

820 

730 

700 

690 

500 

530 

410 

400 

390 

330 

330 



26,227 



671 



44,2702 



4,340 

1,850 

1,370 

7SO 

2,210 

1,950 

1,920 

1,080 

1,120 

500 

1x6 

570 

612 

328 

182 

210 

'60 
424 
164 
220 
97 

*82 



20,155 



Total number of deaths, 5-14, in registration area, 29,679. 
Total number of deaths, 5-14, in the United States, about 50,000. 
Total number deaths preventable, about 33,500. Based upon 1910 U. S. Mortality 
Statistics and Fisher's Preventability Tables. 



* Fisher's average. 



2 Estimated. 



their various bulletins these significant words: "Public health 
is purchasable. Within natural Kmitations a community 
can determine its own death-rate." And the prophecy of 
Pasteur has in some communities gone far toward reaHzation : 
namely, that *'it is within the power of man to rid himself 
of every parasitic disease." 

The economic losses due to the cost of educating for several 
years in public schools the children who die in this period are 
of course a large source of public preventable waste. 



PUBLIC HEALTH AND THE PUBLIC SCHOOLS 



17 



TABLE IV 

Showing the Preventability of Deaths of Children of High-School 
Age, 15-19, EOR 25 Most Numerous Causes of Death in 1910 



2 
3 
4 

5 
6 

7 
8 

9 
10 
II 
12 
13 
14 
15 
16 

17 
18 

19 
20 
21 
22 
23 
24 
25 



CAUSES OF DEATHS 



Pulmonary tuberculosis . . . 
Accidents and undefined . . 

Typhoid fever 

Heart-disease, organic. . . . 

Pneumonia 

Tuberculosis, other parts . . 

Appendicitis 

Bright's disease 

Suicide 

Meningitis 

Rheumatism, articular 

Diabetes 

Scarlet fever 

Diphtheria and croup 

Nephritis, acute 

Endocarditis (heart) 

Epilepsy 

Peritonitis 

Bronchopneumonia 

Cancer and other tumors . . 
Spinal cord, other diseases 

Influenza, grippe 

Intestinal obstruction 

Measles 

Apoplexy, cerebral hem. . . 



No. deaths 
in registra- 
tion area 



S,i66 

2,525 

1,681 

1,158 

1,140 

933 

754 

440 

326 

294 
261 
258 
232 
228 
199 
196 
172 
162 
158 
152 
130 
119 
117 
112 
103 



17,016 



Per cent 

pre- 
ventable 



75 

85 
25 
45 
75 
SO 
40 

70 
10 
10 
50 
70 
30 
25 

55 
50 



50 

25 
40 

35 



67' 



Total No. 
deaths in 
the U. S. 



8,650 

4,230 

2,830 

1,940 

1,920 

1,750 

1,270 

740 

550 

500 

450 

450 

400 

400 

340 

340 

^00 

280 

280 

260 

220 

200 

200 

190 

180 



28,780 



No. pre- 
ventable 
deaths 



6,487 

2,405 
485 
864 

1,177 
635 
286 

350 

45 

45 

200 

280 

102 

85 

154 
140 



100 
50 
76 

63 



14,039 



U. 



Total number of deaths, 15-19, in registration area, 19,772. 

Total number of deaths, 15-19, in the United States, about 34,000. 

Total number of deaths, 15-19, preventable, about 24,100. Based upon 1910 

S. Mortality Statistics and Fisher's Preventability Tables. 

1 Fisher's average for all causes of death. 



The illness and physical-defects losses of both teachers 
and pupils of the public schools are enormous, coming in the 
form of personal and public financial loss, of lowered vital 
efficiency and happiness, and of elimination, non-promotion, 
and retardation at school. 

Combined, the physical-defects and illness losses are very 
great but as yet hardly computable. Ayres, Cornell, and 
others have given good reason to believe from their investi- 
gations that a large share of retardation is due to physical 



iS 



EDUCATIONAL HYGIENE 
TABLE V 



Approximate Expectation of Life in a State that Has Kept Life 
Statistics for Several Years ^ 





MASSACHUSETTS (WHITE) 






1900 


SIX YEARS 
1884-189O 


1880 




AGE 
























Males 


Fe- 
males 


Per- 
sons 


Males 


Fe- 
males 


Per- 
sons 


Males 


Fe- 
males 


Per- 
sons 




O. . . 


44.29 


47.80 


46.05 


40.39 


42.59 


41.49 


44.06 


45-22 


44.64 




I. . . 


53.13 


54-96 


54-05 


49-29 


50.40 


49.85 


51-18 


51.20 


51.19 




2. . . 


54-64 


56-28 


55-46 


52.13 


53-15 


52.64 


53-30 


53-06 


53.18 




3--- 


54.69 


56.31 


55 -SO 


52.37 


53-45 


52.91 


53.88 


53-60 


53.74 




r 4--- 


54-42 


55-97 


55 -20 


52.20 


53.29 


52.75 


54.05 


53-75 


53.90 




S--- 


53 90 


55-50 


54-70 


51-93 


53-02 


52.48 


53-92 


53-67 


53.80 




lO. . . 


50.15 


51-70 


50.93 


48.83 


49-97 


49.40 


51.01 


50.93 


50.97 




IS-.- 


45-79 


47-49 


46.64 


44-78 


45-98 


45-38 


46.85 


46.86 


46.86 




1-20. . . 


41.79 


43-54 


42.67 


41.09 


42.42 


41.76 


43.09 


43-49 


43.29 




25... 


38.23 


39-71 


38-97 


37-79 


39-04 


38.42 


39.81 


40.44 


40.13 




30--- 


34.66 


36.07 


35-37 


34-50 


35-76 


35-13 


36.38 


37.28 


36.83 




35- •• 


31.09 


32.42 


31.76 


31.20 


32.48 


31.84 


32.96 


34-13 


33-55 




40.. . 


27.49 


28.79 


28.14 


27.86 


29.17 


28.52 


29.48 


30.78 


30.13 




45- •• 


23-89 


25.16 


24.53 


24.51 


25-86 


25.19 


26.01 


27-43 


26.72 




SO... 


20.57 


21.74 


21. 16 


21.33 


22.56 


21.95 


22.52 


23-93 


23.23 




55- • ■ 


17-25 


18.32 


17.79 


18.15 


19-25 


18.70 


19.02 


20.43 


19.73 




60... 


14.48 


15-41 


14-95 


15.35 


16.32 


15-84 


15.98 


17.26 


16.62 




65... 


11.70 


12.50 


12. 10 


12.54 


13-38 


12.96 


12.95 


14.08 


13.52 




70. . . 


9.69 


10.31 


10.00 


10.38 


11.03 


10.71 


10.63 


11.60 


II. 12 




75..- 


7.68 


8.12 


7.90 


8.21 


8.68 


8.45 


8.31 


9-13 


8.72 




80... 


6.57 


6.83 


6.70 


6.91 


7.17 


7.04 


7.06 


7.62 


7.34 




85... 


5. 46 


5-54 


5-50 


5-60 


5-66 


5-63 


S-82 


6.12 


5. 97 




90... 


3.98 


4.02 


4.00 
















95... 


2.50 


2.50 


2.50 















The school ages are bracketed at the left. In Massachusetts a "person " four years 
of age in 1884-90 would probably live fifty-three years longer (52.75); m 1880 his 
chances were extended to fifty-four years, and in 1900 to fifty-five years. Recent health 
improvements have probably raised it to fifty-six years. 

1 From Bulletin 15 of the United States Bureau of the Census, entitled "A Dis- 
cussion of the Vital Statistics of the Twelfth Census." 

defects and the absence and illness caused by them.^ I have 
shown that perhaps 25 per cent or more of all absences from 
school is caused by illness and that absence is a very large 

2 See chapter on "Physical Defects and School Progress" in the last edition 
of "Medical Inspection of Schools," and the appendix in this volume. 



PUBLIC HEALTH AND THE PUBLIC SCHOOLS 



19 



TABLE VI 

Approximate Expectation of Life in Another State that has Kept 
Life Statistics for Several Years ^ 



NEW JERSEY (WHITE) 


AGE 


1900 


SIX YEARS 
1884-189O 


1880 


Males 


Fe- 
males 


Per- 
sons 


Males 


Fe- 
males 


Per- 
sons 


Males 


Fe- 
males 


Per- 
sons 


0. . . 

1. . . 

2. . . 

3--- 

r 4... 

j 10. . . 

15... 
I- 20. . . 

25.-- 

30--- 
35--- 
40... 

45--- 
50... 

55--- 
60. . . 

65-.- 
70... 

75--- 

80... 
85-.- 
90... 
95- •• 


44.06 
52-05 
53-63 
53-75 
53-39 

52.86 
49-27 
45.00 
41.04 
37-38 

33-84 
30.29 
26.87 
23-44 
20.18 

16.92 

14.19 

11.46 

9-52 

7-58 

6-47 
5-35 
3-93 
2.50 


48.27 

54-45 
56.07 
56.06 
55-77 

55-28 

51-59 
47.24 
43-12 
39-35 

35-79 
32.22 
28.67 
25.11 
21.64 

18.17. 
15-23 
12.28 
10. 16 
8.03 

6.83 
5-62 
4.06 
2.50 


46-17 
53.25 

54-85 
54-91 
54-58 

54-07 
50-43 
46.12 
42.08 
38.37 

34.82 
31.26 
27.77 
24.28 
20.91 

17-55 

14.71 

11.87 

9.84 

7.81 

6.65 
5-49 
4.00 
2.50 


40.11 

48^-73 
51-66 
52.00 
52.04 

51.79 
48.62 

44.55 
40.72 
37-36 

34-05 
30.73 
27.46 
24.18 
20.97 

17.76 

14.91 

12.05 

9-94 

7-83 

6.71 
5.58 


43-55 
51-08 
53-81 

54-22 

54-25 

53-96 
50.82 
46.79 
43-09 
39-57 

36.18 
32.78 
29-37 
25-95 
22.54 

19.13 
16.09 
13-05 
10.71 

8.37 

7-07 
5-77 


41.83 
49-91 
52-74 
53-11 
53.15 

52-88 
49.72 
45-67 
41.91 
38.47 

35-12 
31.76 
28.42 
25.07 
21.76 

18.45 
15-50 
12.55 
10.33 
8.10 

6.89 
5-68 


45-59 
52.65 

54-39 
54-94 
54-94 

54-71 
51-57 
47.36 
43.29 
39.8^ 

36.26 
32.71 
29.20 
25.70 
22.33 

18.96 
16. 10 
13.25 
10.90 

8-54 

7.40 
6.26 


48.05 
54-23 
55.71 
56.13 
56.03 

55.66 
52.52 
48.40 
44.51 
41.15 

37-76 
34-37 
30.80 
27.24 
23.70 

20.15 
16.89 
13-63 
II. 12 
8.60 

7-36 
6.13 


46.82 

53.44 
55.05 
55.54 
55.49 

55.19 
52.05 
47.88 
43.90 
40.48 

37.01 

33-54 
30.00 
26.47 
23.02 

19.56 
16.50 

13.44 
II. 01 

8.57 

7.38 
6.20 



The school ages are bracketed at the left. 

iFrom Bulletin 15 of the U. S. Bureau of the Census, entitled "A Discussion of 
the Vital Statistics of the Twelfth Census." 



factor in causing retardation. Absence has a proved correla- 
tion with non-promotion, and illness is the chief cause of ab- 
sence, especially the longer absences. Experiments carried on 
by Wallin in Cleveland and by Kohnky^ in Cincinnati 
seem to indicate that mere dental hygiene has probably a 
decidedly favorable effect on the mental and physical status 
2 Kohnky, Journal of Educational Psychology, December, 1913. 



20 EDUCATIONAL HYGIENE 

of school-children. In the Cincinnati investigation a control 
class was used and the results seem to show a direct causal 
relationship between mouth hygiene and school progress.^ 
Doctors and nurses and teachers of the public schools where 
medical supervision is carried on are unanimous in their 
opinion, based on observation, that school progress for very- 
many children is materially hastened by the ehmination of 
their physical defects and the cure of their ailments.^ 

My own studies of the rough data gathered in a survey 
of a number of cities seem to indicate that not less than about 
15 per cent of ehmination, 16 per cent of non-promotion, and 
1 7 per cent of retardation is caused by the illnesses and phys- 
ical defects of school-children. We are not yet ready to state, 
in general nor for any one city, precisely how much an aid 
to school progress and community health medical supervision 
and the various phases of educational hygiene are. The belief 
is warranted that they are great. Before accurate measure- 
ments can be made we must have very much more accurate 
statistical records and reports and much improved super- 
vision by health specialists. Records and reports at the pres- 
ent time are entirely too vague, variable, and meaningless 
for any accurate knowledge of school health work. In a 
later chapter on medical supervision I give a tentative stand- 
ard plan for the administration of educational hygiene, es- 
pecially of medical supervision, and offer there for criticism 
and use a tentative standard terminology and classification 
of the multitudinous ailments of school-children. There it 
will be seen that, according to the best data obtainable, not 
far from one- third of the school-children will, on the average 
and in any one school year, be found to suffer from no ail- 
ments of a serious nature, one-third with teeth defects only, 
one-third with teeth defects and two or more other ailments each.^ 

*Wallm, Dental Cosmos, April, 1913. 

2 See articles in the Psychological Clinic for January, 191 5. 

^ See the writer's survey of Rural School Hygiene in the Report on Rural 
Schools to the Pennsylvania State Educational Association, 1914, State Supt. 
N. C. Schaeffer, Harrisburg, Pa., Chairman. 



PUBLIC HEALTH AND THE PUBLIC SCHOOLS 21 

These facts, then, set forth rather vaguely and inadequately 
the school health problem. About half of the school-children 
may be said to be seriously ailing and defective in any one 
school year and in grave need of the care of school doctors, 
nurses, dentists, physical-training teachers, and others. The 
need is for efficient agencies for discovering the exact health 
status of the pupil population, the health census, and then 
for further efficient agencies for preventing such ailments and 
for getting cured and corrected those found to exist. Un- 
doubtedly this work, if well carried on, will place the school 
in close and intimate association with the home, the public- 
health agencies, the private organizations that may be in- 
terested in health advancement, and with the real life of the 
city or community. This is a consummation, of course, de- 
voutly to be wished. 

The aim of these school systems is to promote the welfare 
of the people by developing social efficiency in each child. 
The relation of educational hygiene to this general aim may 
be observed on analyzing social efficiency into its elements. 
These factors are: 

(i) Vital Efficiency. — Health, freedom from physical de- 
fects, and physical development. (2) Vocational Efficiency. — 
AbiHty to make a good living honestly by performing necessary 
social service. (3) Avocational Efficiency, — The right use of 
leisure, wholesome enjoyment, and genuine happiness. (4) 
Civic Efficiency. — Good citizenship, pubHc interest, ability in 
leadership, and co-operation. (5) Moral Efficiency. — Good- 
will, spirit of social service, skill in promoting goodness. 

It may be seen at once that the five divisions of educational 
hygiene have an intimate bearing on the attainment of these 
supreme ends of education. Especially do they contribute to 
the first and third factors of social efficiency. Foundational 
as it is, health work in the schools cannot be placed second in 
any list of minimal essentials of schooling for a democracy. 
What the draft has revealed we must now combat by all 
means at our command. 



CHAPTER II 
THE PUBLIC-HEALTH MOVEMENT 

Public Health and Public Welfare. — Public health is the 
most fundamental and basic element of social, economic, 
and national efficiency. Wealth is but a symptom and func- 
tion of health. Yet with our innate inclination to consider 
symptoms rather than to grapple with fundamental causes, 
we have, in our systems of social philosophy, either entirely 
left out the element of pubHc health or given to it but pass- 
ing attention. We have developed an immense science of 
economics and a philosophy of wealth, but have left the science 
of pubHc health in a very fragmentary and incomplete state. 
With the recently awakened active interest in the promotion 
of public health the need of scientifically established principles 
is becoming very acute, but with reference to understanding 
pubHc-health needs we are in a state of almost complete chaos. 
During the winter session of the various State legislatures, 
for example, about one thousand bills on pubKc health were 
considered, ranging in importance from reorganizing whole 
State departments of health, or passing model vital-statistics 
laws, to the prohibition of roller towels. Some of the measures 
are insignificant, others unnecessary, while still others exhibit 
the propensity merely to follow certain styles or fashions. 
Doctor Frederick R. Green, the secretary of the Council on 
Health and PubKc Instruction, of the American Medical As- 
sociation, commenting on such floods of bills, says that they 
disclose '^a tendency on the part of the legislatures to follow 
prevailing fads in lawmaking." ^ 

"The public-health movement to-day is going almost 

* The Survey, September 27, 1913, p. 748. 
22 



THE PUBLIC-HEALTH MOVEMENT 23 

too fast/' says Professor Sedgwick/ ''almost faster than the 
teachers and directors of the movement could wish, because 
a great many foolish things are being done to-day in the name 
of public health, and there are pubhc-health fakirs as there 
are quacks and dealers in quackeries." 

Since the interest in pubhc health has gained such an 
impetus, and since so much activity is being displayed by 
governmental, civic, and private organizations, it becomes 
imperative to see that the movement is directed along proper 
channels in order that an unnecessary waste of energy and 
money may be prevented and that the fragments of public- 
health science may be woven into a coherent entity for the 
guide of legislators and public-health administrators. 

At this stage of the movement it is necessary, therefore, 
to take stock of the methods used, of the forces at work, and 
of the achievements accomplished. It is a tremendous task 
and the present paper is but an elementary attempt to state 
the problem. 

Preventive Medicine. — The foundations and possibilities 
of this great health movement lie largely in preventive 
medicine. "Although drugs are helpful to the individual in 
that they may lessen his suffering and hasten his recovery, 
they are of no avail in preventing disease in a population. 
Take the best-established cures in medicine, the drugs known 
as 'specifics' — ^iron in anemia, mercury in syphilis, quinine 
in malaria, antitoxin in diphtheria and tetanus — and who can 
say that they have exerted the slightest effect upon the in- 
cidence of these diseases in human communities? On the 
other hand, see what preventive medicine has accompKshed 
in combating puerperal and surgical fevers, smallpox, malaria, 
yellow fever, rabies (in England it no longer occurs), Mediter- 
ranean fever, plague, and relapsing fever. . . . Many hun- 
dreds of thousands of lives throughout the world are now 

*"The Public Health Movement in America — ^To-day and To-morrow," 
an address delivered before the Association of Life Insurance Presidents, 
December, 19 13. 



24 EDUCATIONAL HYGIENE 

saved annually by preventive medicine." ^ And preventive 
medicine is but in its infancy. Its possibilities are immeas- 
urable. With every new medical discovery new possibilities 
arise. The foundation of the public-health movement has 
already become enormous and it is widening from day to day. 

The Aims of the Public-Health Movement. — The public- 
health movement may be broadly defined as a social effort 
to prevent disease, to lengthen the Kf e and usefulness of every 
member of society, and to afford opportunities for a normal 
physical and mental development of society. 

In its broad aspects pubHc-health work consists in pre- 
venting preventable diseases by means of early diagnosis and 
efficient quarantine, in affording opportunities for effective 
treatment and cure of the sick, in combating filth, un- 
hygienic Hving, insanitary conditions of work and habita- 
tion, in health education of individuals and communities, and 
in providing opportunities for sunlight, fresh air, pure food, 
and recreation. Each of these main branches divides itself 
into a great number of constituent elements. I shall not 
even attempt to enumerate them but shall indicate some of 
the results already obtained and some of the problems to be 
attacked.^ 

Prolongation of Life. — It has been estimated with more 
or less accuracy that the average length of human Hfe in the 
sixteenth century was between eighteen and twenty years, 
and at the end of the eighteenth century was a Httle over 
thirty years; while to-day it varies in different countries from 
less than twenty-five to more than fifty years. The general 
death-rate of the city of BerHn has been reduced from 32.9 
per 1,000 in 1875 to 16.4 in 1904, and to 14.7 in 1910. The 
death-rate of London has decreased from 20.9 for the four- 
year period of 188 1-5 to 12.7 in 19 10; for the same period 

1 Professor Geo. N. F. Nuttall, of Cambridge, England, "Proceedings of the 
Fifteenth International Congress of Hygiene and Demography," vol. IV, part 
2, p. 417. 

''See Devine's "Seventeen Health Demands" in The Survey for July 4, 1914. 



THE PUBLIC-HEALTH MOVEMENT 



25 



Dublin shows a decrease from 27.5 to 19.9, Amsterdam from 
25.1 to 12.4, Stockholm from 24.3 to 14.6, New York from 
27.5 to 15. 1 in 1911, Chicago from 21.5 to 14.6, and so along 
the line. The average death-rate in the whole of the regis- 
tration area of the United States has decreased from 17.6 in 
1900 to 14.2 in 1911. While the average death-rate all over 
the civilized world has for the last quarter of a century been 
constantly declining, the chief gains in saving life have been 
made at the beginning of the course, in the younger age groups. 
The death-rate in the later age groups, above forty, has been 
constantly increasing.^ 

The following is a table showing the death-rates for males 
and females, by age groups, for the years 1900 and 191 1 re- 
spectively, for the registration States as they were constituted 
in the year 1900.^ 

COMPARISON OF MORTALITY OF MALES AND FEMALES BY AGE 

GROUPS 
Death-Rates per 1,000 Population 



AGE 


MALES 


FEMALES 


igoo 


1911 


Per cent 

increase or 

decrease 


1900 


1911 


Per cent 

increase or 

decrease 


Under 5 

S- 9 

10-14 

15-19 

20-24 

25-34 

35-44 

45-54 

55-64 

65-74 

75 and over. 


54-2 
4-7 
2.9 
4.9 
7.0 

8.3 
10.8 
15.8 
28.9 
59.6 
146. 1 


39.8 

3-4 
2.4 

3-7 

5-3 

6.7 

10.4 

. 16. 1 

30.9 
61.6 

147.4 


-26.57 

— 27.66 

-17.24 

-24.49 

-24.29 

-19.28 

+ 3-70 

+ 1.90 

+ 6.92 

+ 3-36 

+ 0.89 


45 
4 

3 

4 

6 

8 

9 

14 

25 

53 

139 


8 
6 
I 
8 

7 
2 
8 
2 
8 
8 
5 


33-3 
3-1 
2.1 

3-3 
4-7 
6.0 

8.3 
12.9 
26.6 

55-1 
139.2 


-27.29 

-32.61 

— 32.26 

-31-25 

-29.8s 

-26.83 

-15.31 

-9-iS 

+ 0.78 

+ 2.42 

— 0.22 


1 All ages 


17.6 


15.8 


— 10.23 


16.5 


14.0 


-15.15 



From this table one can readily see: 

I. That men's chances for longevity are considerably 

iSeeTablesII, V, VL 

2 Table quoted by Louis I. Dublin, in American Journal of Public Health, 
December, 1913, p. 1263. 



26 



EDUCATIONAL HYGIENE 



poorer than women's, and that the reduction in the mortahty 
rates has benefited women more than men; and 

2. That the mortality rates for males, in 191 1, exhibit a 
tendency to increase, beginning with the age group of from 45 
to 54, and of women with the age group from 55 to 64. These 
increases in death-rates after 45 are chiefly due to the so-called 
degenerative diseases (including apoplexy, paralysis, and the 
diseases of the heart, circulatory system, kidneys, and liver). 
Mr. Rittenhouse, of the Life Extension Institute, has compiled 
the following comparative table of these diseases, for the years 
1880 and 1909, for Massachusetts:^ 



DEATH-RATES FOR DEGENERATIVE DISEASES PER I0,000 

POPULATION 



Ages 


1880 


1909 


Per cent of 
increase 


All 


23.21 

7.92 
2.91 
2.8s 
3.10 

4.95 

10.13 

19.70 

39.01 

102.05 

261.10 


43.26 

10.36 

3.95 
4.72 

5.43 

8.09 

18.79 

37.84 

91.30 

212.93 

558.20 


86.38% 

30.8 

35-7 
65.6 
75.2 
63-4 
85.5 
92.1 

134 -o 
108.7 
113-0 


Under 5 

5-9 

10-14 

15-19 

20-29 

30-39 

40-49- • 

SO-59 

60-69 

70 and over. . . 



It can be seen in the right-hand column that the great 
increases are for persons over forty, and above that age 
the increase from 1880 to 1909 is from about 23 to 43 per 
cent. 

Another disease deserving consideration in this connection 
is cancer. Approximately 75,000 deaths annually are at- 
tributed to this disease in the United States, and the indica- 
tions are that a steady increase of the death-rate from cancer 
is taking place in this country at ages over forty-five. Cancer 
is now of even greater importance than tuberculosis. Whether 
^Popular Science Monthly, April, 1913, pp. 376-380. 



THE PUBLIC-HEALTH MOVEMENT 27 

this rise of cancer is a result of a better recognition of the 
disease or whether it is a real rise cannot as yet be definitely 
determined. But there is a great possibility for prevention 
of the disease by education and proper diagnosis in the early 
stages. Recently a national society has been formed for this 
purpose. 

The very large increase in the death-rates from these 
diseases, particularly noticeable in the age groups above forty, 
is a sad commentary upon our civiHzation. The wear and 
tear of modern life, the nervous strain and high tension to 
which we are all subjected, ill adaptation to changing con- 
ditions, unsound habits of life, and the pernicious after-effects 
of the diseases of childhood, youth, and middle age are re- 
sponsible for this disquieting phenomenon. 

How living habits affect mortahty is stri^ngly demon- 
strated by the experience of the United Kingdom Temperance 
and General Provident Institution, described by Doctor E. L. 
Fisk.^ According to the records of the above-mentioned in- 
stitution, ^'two large bodies of hves, almost equal in numbers, 
and homogeneous except for the use of alcohol, moved along- 
side of each other for forty years, and the group of abstainers 
at all times exhibited a markedly superior vitaHty to the 
other group, the non-abstainers, the total difference in favor 
of the abstainers during the period covered being 27.4 per 
cent, although the mortahty among the general, or non- 
abstaining, class was only 91 per cent of that expected ac- 
cording to the British 051 Table, representing the experience 
of sixty-three British officers." We have no similarly direct 
statistical evidence on the effects upon the death-rate of 
bad housing conditions, insanitary working conditions, lack 
of school medical supervision, lack of health education, etc. 
We know, however, that dark rooms and dusty trades, the 
use of phosphorus, mercury, lead, and other similar sub- 
stances in manufacture, and the failure to provide for the 
health of the young, are potent causes of much morbidity and 
1 Popular Science Monthly for April, 1913, p. 382. 



28 EDUCATIONAL HYGIENE 

mortality. It has been estimated that in this country each 
year about 500,000 industrial accidents occur, at least one- 
half of which might be prevented; that we have in our midst 
every year 13,500,000 cases of industrial sickness, involving 
a loss to society of about $800,000,000, and that of this loss 
we can save at least one-quarter.^ Here is a burning problem, 
but the public-health movement cannot as yet boast of 
great accomplishments in these directions. Studies are be- 
ing made and remedial legislation devised, but the machinery 
for its enforcement is inadequate, and, what is almost as im- 
portant, no adequate educational machinery is at work to in- 
struct and train the large masses of our people in personal 
hygiene, sound health habits and ideals of life, and the pre- 
vention of disease. 

T3rphoid Fever. — The prevalence of typhoid fever is a 
good index of social and sanitary conditions. It is a disease 
whose etiology and method of transmission are well known, 
and is therefore well controllable. It is a disgrace to our 
civiHzation that, in the registration area of the United States 
in 191 1, there should have been from this one disease 12,451 
deaths. These deaths from typhoid mean at least 124,510 
cases of prolonged sickness (ten times the number of deaths) 
whose origin was clearly due to the drinking and eating of 
food which was contaminated by the excreta of typhoid pa- 
tients. In the majority of our cities drinking-water is obtained 
from rivers and lakes into which typhoid-infected sewage is 
or may be discharged. It is gratifying to learn that many of 
the cities are taking steps to safeguard the quality of the 
drinking-water by installing filter plants. But still a com- 
parison of the death-rates from typhoid in European and 
American cities is a severe indictment of our indifference in 
matters of health and life protection. The following is a 
comparative table of the death-rates from t3^hoid fever in 
certain large cities of the world for the year 19 10: 

1 John B. Andrews, "Industrial Diseases and Physicians," Journal of the 
American Medical Association, April 15, 191 1, vol. 56, p. 113 2. 



THE PUBLIC-HEALTH MOVEMENT 



29 



DEATHS FROM TYPHOID FEVER PER 100,000 POPULATION 



City 


Death-rate 


City 


Death-rate 


Hamburg 


2.5 
3.6 
4.0 
4.1 
6.7 
4.2 


New York 

Boston 


II. 6 
II. 6 

13-7 
17.4 
23.2 
15-5 






Chicago 


Vienna 


Philadelphia 

Washington, D. C. 
Average 


Paris 









Not all of the typhoid fever, of course, comes from pol- 
luted water supplies. A great deal of it comes from polluted 
milk and its products, from oysters, vegetables, shell-fish, 
etc. ; and a good deal of it also comes from the polluted fingers 
of those who are either carriers (well, yet carrying the germs) 
or who attend patients and do not take care to clean and dis- 
infect themselves properly. It has been estknated that at 

TYPHOID FEVER DEATHS IN INDIANA 
By Ages 



160 




q 1 2 34 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 90 
1 2 ^3 4 < ^5 9 14 19 /24 29 34 39 44 49 54 59 64 69 74 79 90 

! 1 9 1 2 "I ^^^ -Average for Last Ten Years 



Typhoid fever, like tuberculosis, finds more victims in the years imrnedi- 
ately following the school period, possibly somewhat earlier. Typhoid is 85 
per cent preventable, according to Fisher and others. Most deaths occur from 
August to December. 



30 EDUCATIONAL HYGIENE 

least lo per cent of typhoid in New York City is of this so- 
called secondary origin. Here, again, the need of education 
in hygiene is obviously a potent force in disease prevention. ^ 

A great deal also remains to be done in the country dis- 
tricts, where the prevalence of typhoid is very great. Much of 
our city typhoid is of direct rural origin, as evidenced by the 
characteristic increase of the wave of prevalence of the dis- 
ease in the early autumn when people return from their sum- 
mer vacations in the country. 

Pure Food. — The fact that many cases of typhoid and 
other diseases are derived from milk and other perishable 
foods leads to the consideration of the food problem, which of 
late has received much popular attention. Unfortunately, 
however, perhaps too much emphasis is being laid on the use 
of preservatives in canned foods and not enough stress on the 
control of perishable foods, which are the most important 
carriers and disseminators of disease. Very few instances of 
death or serious illness can be clearly traced to food preserv- 
atives or to such so-much-discussed substitutes as oleomar- 
garine, glucose, etc., but hundreds of thousands of deaths 
are undoubtedly due directly to contaminated milk, water, 
meat, oysters, and other perishable foods. The pubHc-health 
movement has not as yet definitely stated the food issue or 
clearly indicated its proper mode of solution. 

The food problem has, of course, as great an economic as 
a health aspect. The economic element of the problem is 
very important but it should not be confused with the health 
issue. To add apple jam to raspberry jelly, or potato flour 
to sausage, may be good business and bad ethics, but it is 
largely a matter of indifference from the point of view of 
public health. Whether a certain appetizing and high-priced 
preparation or expensive cut of meat has Httle nutritive value 
is also almost entirely an economic problem. That March 
or April eggs are kept in cold storage till November and then 

^See Winslow's article on "Man and the Microbe" in the Popular Science 
Monthly for July, 1914. 



THE PUBLIC-HEALTH MOVEMENT 3 1 

bring better prices than they would in April is also a matter 
of practically no concern to the public-health administrator. 
His concern is to see that the eggs or meat are fresh and sound 
when put into cold storage, and also that when once taken 
out of storage and allowed to thaw they are not put there 
again. 

Our present stage of industrial development has created 
a need for cold storage and the production of foods on a factory 
scale. It would be useless to combat this tendency. It is 
necessary, however, to control this modern wholesale produc- 
tion of foods in a rational and scientific manner and see that 
the conditions under which they are being produced are sani- 
tary, that the workmen employed are healthy and cleanly, and 
that the raw products used are free from contamination and 
disease. The sporadic and irrational outbursts of revolt with 
little scientific basis have resulted in a hodge-podge of legisla- 
tion which is a hardship and a nuisance to the honest producer, 
and is, at best, of Httle benefit to the consumer. At the pres- 
ent time there is practically no uniformity of standards and 
no uniformity of requirements. What may be legal in one 
State may be illegal in another, and vice versa. As Mr. Dunn, 
the author of a standard digest of food laws, says, "pure food 
legislation is a mass of inconsistencies. The federal authorities 
and the State of Wisconsin say that flour bleached with nitro- 
gen of peroxide is injurious. But Missouri, Oklahoma, Indi- 
ana, South CaroHna, and Wyoming permit its sale if the 
bleaching process is indicated in the label. Illinois has made 
it illegal to bleach grain with sulphur dioxide, yet the sale of 
this grain, when properly labelled, is permitted by the federal 
law."i 

What the public-health movement has not as yet accom- 
plished in this direction is scientific standardization and the 
securing of uniformity of legislation. If, after reliable scientific 
data on a certain problem had been obtained, the represent- 
atives of the several States would come together and agree 
» New York Times for January 25, I9i4« 



32 EDUCATIONAL HYGIENE 

on a certain method of procedure and secure approximate or 
standard legislation for its enforcement, the spectacle of two 
adjoining States having different laws on the subject, with 
all its injurious effects, would be made impossible. 

There are many matters which could even at present be 
dealt with adequately if a common standard were adopted. 
Why, for example, should the unscrupulous milk-dealer whose 
milk has been barred out of one city, because it has been 
found to be infected with typhoid-fever germs, be allowed to 
sell it in another city where the regulations are less exacting 
and thereby cause an epidemic of the disease? Why should 
the owner of tuberculous cattle be allowed to sell his meat 
within a State when the federal authorities would condemn 
it for interstate commerce? These are some of the many 
problems concerning the food question which the public- 
health movement must solve in the interest of efficient ad- 
ministration and the proper protection of society, and which 
can only be accomplished by proper co-operation of the va- 
rious public and private health agencies.^ 

Infant Mortality. — ^As some one has said, the business of 
being a baby is an extremely hazardous one. As late as the 
year 191 2, with all our efforts to reduce infant mortality, out 
of the total of 838,251 deaths in the registration area of the 
United States, 147,455 deaths, or 17.6 per cent, occurred among 
children under one year of age, and 204,639 deaths, or 24.4 
per cent, among children under five years of age. Almost 
one-fourth of all the deaths occur before the child reaches the 
age of five, three-fourths of which occur in the first year of life. 
Fortunately there has been a marked reduction in the infant 
death-rate in recent years. The following table gives a com- 
parison of the death-rates under one year of age in the same 
States and cities for the years of 1900 and 191 1. 

In some States and cities the reduction in infant mortality 
was more than 30 per cent during this twelve-year period. 
In Rhode Island it has decreased from 197.9 to 138.6 per 
» See also the chapter on School Feeding. 



THE PUBLIC-HEALTH MOVEMENT 33 

DEATH-RATE PER 1 ,000 POPULATION UNDER ONE YEAR OF AGE 



Area 


igii 


I goo 


Per cent 
of decrease 


STATES OF THE REGISTRA- 
TION AREA IN 1900 

Connecticut 

Maine 


129-5 
130.9 
1 10. 9 

143.3 
III. 4 

150-3 
13I-5 
128.8 
138.6 
102.0 

104.8 

131.9 
170.0 

123.3 
160.9 
123.8 
130.6 
141-9 


159-3 
156.8 
144. 1 
177-8 
121. 3 
172.0 
167.4 
159.8 
197-9 
122. I 

152.2 
162.3 

274-5 
146.6 
194. I 
162.4 
189.4 
201 .9 


19 
17 
23 
19 
8 

13 
21 

19 
30 
16 

31 
19 
38 
16 
% 17 
24 
31 
30 


Massachusetts 


Michigan 


New Hampshire 


New Jersey 


New York 


Rhode Island 


Vermont 


CITIES WITH 100,000 POPU- 
LATION OR over: 
San Francisco 


Denver 


Washington, D. C 

Chicago 

Boston 


St. Louis 

New York City 


Philadelphia 





1,000 children under one year of age. In the city of Wash- 
ington, D. C, it has been reduced from 274.5 in 1900 to 170.0 
in 191 1, and so on. 

The deaths of infants have both hereditary and environ- 
mental causes, the latter being much more important; diar- 
rheal and respiratory diseases which result from bad feeding, 
bad air, filth, ignorance, carelessness, and poverty being the 
chief causes of infant mortahty. The main bulk of infant 
deaths, in the last analysis, are of an environmental origin 
and can be annihilated only by a change in environment, in- 
cluding proper education. 

Milk Stations. — One of the potent factors in reducing 
infant mortality has been the milk station. Thorough and 
repeated studies of infant mortahty here and abroad have 
shown that the chances of a breast-fed child are at least five 
times better than the chances of an artificially fed baby. 
Nature did not intend that cows should nurse human babies, 
and our carelessness and ignorance have added additional 



34 EDUCATIONAL HYGIENE 

dangers to this anomaly. If a large percentage of our babies 
must, for economic and other reasons, be artificially fed, then 
steps must be taken to secure for them safe food. Whenever 
this has been tried and milk depots established, infant mor- 
tality has been decreased. 

Education of mothers at the milk depots, at the schools, 
or both in one, is a factor in the situation whose importance 
should not be underestimated. In his paper on "Infant 
Milk Depots,'' read at the Conference on Infant Hygiene 
held in conjunction with the Philadelphia Baby Saving Show, 
191 2, Doctor Rowland G. Freeman estimated on the basis of 
much experience that milk stations plus education of mothers 
can produce a 60-per-cent reduction in infant mortality, of 
which 15 per cent should be credited to instruction, leaving a 
net gain of 45 per cent due to pure milk.^ These figures are 
almost as arbitrary as they are optimistic. We have no 
means to measure the importance of instruction in hygiene, 
and nowhere in this country have we secured a 60-per-cent 
reduction in infant mortality. One reason for our failure to 
secure it lies in the fact that we have not taken steps to de- 
crease infant mortality from the so-called congenital dis- 
eases from which deaths occur and which constitute 37 per 
cent of the total infant mortality in the registration area dur- 
ing the first month of life. The greatest reduction in mor- 
tality has taken place in the case of diarrheal diseases, then 
in respiratory, and very little in congenital diseases, includ- 
ing in this class of diseases congenital debility, malformations, 
premature births, injuries at birth, etc. 

Prenatal Work. — To bring about a further reduction in 
infant mortality the public-health movement must devise 
means for reducing the number of deaths from congenital 
diseases. This can in a large measure be accomplished through 
centres for prenatal care of the mothers. The report of the 
Russell Sage Foundation on "Prenatal Work in Certain 
American Cities," presented at the Fifteenth International 
* Proceedings of the Conference on Infant Hygiene, 1913, p. 201. 



THE PUBLIC-HEALTH MOVEMENT 



35 



DIARRHEAL DISEASES IN INDIANA 
By Ages 



1300 



1200 



1100 



1000 



900 



800 



700 



600 



500 



400 



300 



200 



100 



[^ 






































ft 


i 






































w 


1 








































1 








































1 








































1 






























% 










1 








































1 








































Ij 








































II 








































II 








































Ml 


^ 




































n 




II 


1 


li 


■^ 


■^ 


■^ 




■(^ 


■^ 


■^ 


■^ 


f^ 


■P 


ll 


il 


■1 


1 


1 


li 


ll 


ll 


m 




■ I Ifci^l I — I 111 fl I — I I — I iWWI !■■■! I — I I^WI I ^11 IBil II M 

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 90 
9 14 19^24 29 34 39 44 49 54 59 64 69 74 79 90 

Average for Last Ten Years 



These diseases are the chief infant destroyers and are largely preventable. 
Can we not train for this phase of parenthood in the schools? 



36 EDUCATIONAL HYGIENE 

Congress on Hygiene and Demography in 191 2, shows that 
the work is still in the initial stages, there being but a few 
scattered efforts here and there, ^ ReaHzing the lack of care 
of expectant mothers and the resultant appallingly great 
death-rate from congenital diseases, Doctor Newmayer ad- 
vocates municipal supervision of maternity.^ 

*' There should be legislation which would require all 
hospitals and dispensaries conducting an outdoor service to 
report to the health ofhcer the names and addresses of all 
expectant women presenting themselves at these institutions 
for confinement. The city authorities should have trained 
nurses detailed to visit these prospective mothers during the 
last month or two of pregnancy, observing any signs of ab- 
normahty, instructing the mother in personal hygiene^, care 
of the breasts, and preparing the mother for the time of labor. 
The nurse should continue her visits after the birth of the 
child, in order to instruct in the care and feeding of the baby. 
Such precautions would reduce materially the early deaths 
by avoiding many accidents and would also assure more 
breast-fed babies. In such work the visiting municipal nurse 
would be a logical solution of the midwife problem. Foreign 
mothers, realizing the value of the kind of care and attention 
given to them, would naturally wean themselves away from 
the services of careless and uncleanly midwives, and those 
midwives remaining in practise would be compelled to be- 
come more skilled and painstaking in their work." 

This is but a logical extension of the work which is now 
being carried on by the larger cities of the country in the 
interests of the conservation of the child and which is bound 
to expand. Public schools through home-visiting nurses 
and consultation hours at schools for mothers and expect- 
ant mothers are already doing much valuable service. The 
twentieth century has been dedicated to the welfare of the 
child, and the promise is great. 

1 Ellen C. Babbitt, Proceedings of the Congress, vol. 3, pt. i, p. 304. 
^S. W. Newmayer, Proceedings of the Congress, vol. 3, pt. i, p. 402. 



THE PUBLIC-HEALTH MOVEMENT 37 

School Medical Supervision. — One of the first activities 
in the direction of child conservation was medical supervision, 
or ''inspection," of school-children. When first organized, it 
met with the objection that it was a measure to pauperize 
the people, forgetting that pubhc schools were inaugurated 
as pauper schools and that now they are compulsory. The 
experience of the last fifteen years goes to show that the com- 
munities that have introduced medical school inspection have 
been entirely justified in their expenditures by assuring to 
their future citizens a good start in life, since the majority of 
the children's ailments and incipient diseases are being dis- 
covered at a period when they can easily be remedied. Many 
of the parents of the children who are found suffering from 
one or another physical defect take steps to have these de- 
fects corrected or cured. Many of them, however, are too 
indifferent, too poor, or too ignorant to take the proper action 
and are, unfortunately, more ready to evade health advice 
than to follow it. And here is the point where medical school 
inspection frequently fails. As at present constituted, it does 
not commonly go much beyond the pointing out of defects, 
leaving it to those most interested in the welfare of the chil- 
dren to have them attended to and treated. A recent study 
of the efficiency of the system based on the records of four 
schools in the city of New York showed that when the school 
authorities co-operate with health officers a very high per- 
centage of treatments is obtainable, and where there is no 
such co-operation the percentage of treatments does not in 
any class of ailments exceed 70 per cent. Then, of the cases 
treated, at least 25 per cent resulted in "no cure" or ''no 
improvement." ^ 

Whooping-Cough. — Great strides have been made in child 
conservation, yet in this field a great deal remains to be done. 
We have not as yet turned at all toward prevention of a very 
serious and fatal disease which kills many thousands of chil- 

1 E, H. Lewinski-Corwin, "The Practical Necessity of School Climes," a paper 
read before the Fourth International Congress of School Hygiene, Buffalo, 
N. Y., 1913, and later printed in the Popular Science Monthly for May, 1914. 



40 



35 



30 



25 



20 



15 



1 



MEASLES DEATHS IN INDIANA 

By Ages 



1 



I 



Hi 



ba 



_a 




40 



35 



30 



25 



20 



15 



10 



5 10 15 20 25 80 85 40 4-5 50 6.5 60 65 70 75 80 90 
9 14 l§/24 29 34 39 44 4-9 54 5^9 64 69 74 79 90 

■Average for Last Ten Yeaj:s 



^ 



^. 



Showing the ages when measles are most fatal and common and the impor- 
tance of home care in the pre-school years. 



700 



600 



500 



400 



300 



200 



100 



TUBERCULOSIS DEATHS IN INDIANA 
By Ages 



lb 



- 




I 




700 



600 



)00 



400 



300 



200 



100 



1 2 3 4 5 10 15 M 25 80 35 40 45 50 55 60 65 70 75 80 90 

1 2 3 4 v5 9 14 19/2.4 2B 34 39 44 49 54 59 64 69 74 79 89 

11912 ' 



^ ^^^^ Average for Last Ten Years 

While tuberculosis (all forms) is not relatively very frequent in the school 
ages according to this chart, yet deaths from tuberculosis stand near the first 
in causes of death among school-children, and the school must help eliminate 
the deaths of former pupils. 

38 



DIPHTHERIA DEATHS IN INDIANA 
By Ages 



180j 



160 



140 



120 



100 



80 



6.0 



40 



>2Q 



Mm 



m 



■■1 



^ 



isa 



160 
140 



120 



100 



80 



60 



40 



20 



1 2 3 4 5 10 15 20 25 30 35 40 45 50 55 60 65 70 

1 » 3 4 ^5 9 14 19 ; 24 29 34 39 44 49 54 59 64 69 7S 
2|^§- 1912 V ^^^-Avetage far Last Tea Yeats 

Diphtheria finds its victims in the pre-high-school yiars. Most deaths 
occur from September to January. 

SCARLET FEVER DEATHS IN INDIANA 
By Ages 




^-Average for Last 
Ten Years 

Scarlet fever is another disease of the pre-high-school period, quite largely. 
Deaths occur throughout the school year, but the number is a third as great 
throughout the summer. 

39 



40 EDUCATIONAL HYGIENE 

dren per annum and the death-rate of which is as high as that 
of scarlet fever and, in some parts of the country, much higher. 
I refer to whooping-cough. The recent reports of Doctor 
Rucker, of the United States Pubhc Health Service, and of 
Doctor John Lovett Morse, of Harvard, deserve serious con- 
sideration. It is true, as Doctor Rucker says, that, "if bubonic 
plague were to kill as many children in the United States in 
one year as whooping-cough does, the whole world would 
quarantine against our country/' And yet the disease is 
popularly regarded as of a trifling nature, and scarcely any 
measures are being taken to limit its spread and diminish 
the death-rate from it. Only twenty-nine of the forty- three 
States that answered an inquiry made by Doctor Morse re- 
quire reporting of the disease to the health departments, and 
in those where notification is required very little attention is 
paid to it by physicians.^ 

Disinfection after this disease is required by law in only 
four States of the Union and "recommended but rarely en- 
forced" in but one. In some States there is no law forbid- 
ding the attendance of children with whooping-cough at 
schools; others forbid but have no regulations as to how 
long they should be kept out of schools. The same inade- 
quacy and lack of definiteness relates to regulations pro- 
hibiting the school attendance of other children in the fam- 
ily. And then, "there is almost no provision for the hos- 
pital treatment of whooping-cough in this country." There 
are only a few hospitals in the country that have provisions 
made for these cases. In this connection it may be of in- 
terest to quote the medical officer of the Local Government 
Board of London, who, in speaking of whooping-cough and 
measles, says, "the most hopeful line of action in respect to 
both of these diseases appears to He in the hospital treatment 
of patients for whom adequate domestic nursing cannot be 
secured." 2 

^"Whooping-cough," Journal of the American Medical Association, May- 
Si, 1913, pp. 1677-1680. 
2 Forty-first Annual Report of the Local Government Board, 1911-12, p. xxv. 



THE PUBLIC-HEALTH MOVEMENT 41 

There is also no provision for the treatment of these cases 
in the out-patient departments of the hospitals. In the ma- 
jority of the clinics the children are not allowed to return for 
treatment for fear of infecting other children in the waiting- 
rooms. In some clinics they are allowed to return and are 
*' treated on the sidewalk," at the beginning or end of the 
clinics. In a few clinics only are these cases treated at an 
entirely different hour from the other patients. We have 
here an important and serious task before us. 

Contagious Diseases. — The control of contagious dis- 
eases and the matter of efficient home and school quarantine 
occupy a central position in public-health administration. 
Contagious diseases come and go in waves or cycles recurring 
more or less regularly despite the comparatively definite 
knowledge we possess of the causes and methods of trans- 
mission of some of them. To what extent iscjlation or segre- 
gation of the sick is an element in the control of such diseases 
we have no direct statistical data to determine. We know 
that rise and fall in the waves is dependent on the ratio of 
the number of infected persons to the available infectable 
population. We can observe this particularly well with ref- 
erence to some diseases, like smallpox, for instance. When 
the occurrence of cases of smallpox becomes known in a com- 
munity there is a universal rush for vaccination and the epi- 
demic soon dies out. After a lapse of a few years, during 
which no thought has been given to the disease and during 
which immunity in many instances has ceased and the avail- 
able infectable population has increased, the wave begins to 
rise. This is probably true of every contagious disease. The 
difference in the incidence of the same disease therefore is an 
indication of certain conditions with reference to immunity. 
Segregation and isolation of cases is undoubtedly the most im- 
portant movement in the situation, the extent of which we are 
thus far unable statistically to determine. The comparison of 
the two curves of incidence of measles in Philadelphia and 
New York shown on a chart pubHshed by the Prudential 



42 EDUCATIONAL HYGIENE 

Life Insurance Company suggests that the tenement-house 
congestion of a large portion of the population of the city 
of New York may be the reason for the greater incidence 
of measles in New York than in Philadelphia. 

Vital Statistics. — ^As can perhaps be seen from this hasty 
review, our community health programme has not been worked 
out in detail; plans for a rational development have not been 
laid out carefully and with precision; the various elements 
entering the field have not been scrutinized, balanced, and 
weighed against each other. There is a great deal of dilettan- 
teism and inefficiency about our pubHc-health administration. 
One reason for this state of affairs is lack of the indispensable 
bases of correct judgment, adequate vital statistics. When 
only 60 per cent of the population of this country is included 
in the registration area, when our return^ as they exist are 
incomplete and unreliable, and then, when collected, no ade- 
quate analysis of them is made in most of the communities, 
how can we expect to be able to direct the course of pubKc- 
health administration with precision? In very many in- 
stances, in view of the lack of adequate reliable data, we have 
to depend on theories and suppositions which may or may 
not be correct, having no foundation in definite ascertain- 
able facts. 

Take as an average example the antituberculosis cam- 
paign. In his masterful pamphlet on ^'The Fight Against 
Tuberculosis and the Death Rate from Phthisis," ^ Karl 
Pearson takes exception to certain assertions and points out 
with great acumen the flimsy and scanty grounds from which 
we draw our deductions with reference to the various factors 
in the fight against tuberculosis. The following is an example 
of perfectly sound reasoning for which no statistical evidence 
is at present available. The Department of Health of the 
City of New York has recently published a study made by 
the Council of Jewish Women on ^'The Subsequent History 
of Patients Discharged from Tuberculosis Sanatoria."^ San- 
^ London, 1911. 2 " ]V[onograph Series," No. 8, October, 1913, p. 18. 



THE PUBLIC-HEALTH MOVEMENT 43 

atoria statistics are extremely poor, and the report, after an 
analysis of the medical data of three tuberculosis sanatoria, 
says: "A hasty study of the foregoing three tables might 
lead to the conclusion that sanatorium treatment of the tu- 
berculous was largely futile. As a matter of fact, however, 
this would be a great mistake. The work done by the san- 
atoria is not only highly beneficial to the patients, but is abso- 
lutely indispensable in the campaign against tuberculosis." 

This view is probably entirely right but it does not follow 
from the statistics analyzed. If public health is ever to be 
raised to the dignity of a science with sufficient authority to 
bestow on its adepts the degree of D.P.H. (Doctor of Public 
Health), it must endeavor to procure indisputable proof for 
its assertions and beliefs. We are not yet sufficiently aroused 
to the crying need of what Professor Pearson calls ^'an effi- 
cient medico-statistical logic." 

Municipal Expenditures for Health. — In spite of the oft- 
repeated saying that an ounce of prevention is worth more 
than a pound of cure, and in spite of the wide-spread recog- 
nition of the fact that pubHc health is purchasable, our com- 
munity appropriations for public health do not indicate that 
we apply these principles on a large scale in practise. 

Out of a total $449,219,789 spent by 184 cities of the 
United States in 1910, $9,059,173, or 2 per cent only, went 
for health conservation proper.* The average per-capita 
cost of city administration in « the United States (exclud- 
ing payments for expenses of pubHc-service enterprises) was 
$16.45 in 1 9 10. Of this amount only 33 cents went for health 
conservation, about one-fiftieth. The smaller the cities, the 
smaller is the average per-capita cost for pubHc health. In 
the cities of Group I, i. e., cities having a population of 
300,000 or over, the average for health conservation is 41 
cents; in the cities of Group II (from 100,000 to 300,000 
population) it falls to 27 cents. Cities of Group III (popu- 
lation 50,000 to 100,000) spend 21 cents per capita, and those 
» "Statistics of Cities, 1910," p. 135. 



44 EDUCATIONAL HYGIENE 

of Group IV (population 30,000 to 40,000) can boast of an 
expenditure for health of but 19 cents. ^ 

The health conditions in the smaller towns and country 
districts are particularly unsatisfactory. 

Conclusion. — The foregoing cursory review presents the 
main problems of the pubHc-health movement, which is 
gaining a tremendous impetus in this country. It can be 
seen that a great deal remains to be done, but the most im- 
portant problems facing the movement are education, con- 
centration, and co-operation, all essential to the conservation 
of effort and to the checking of unnecessary waste of energy 
and money. After a statement of the hereditary basis of 
health work in the next chapter, the later chapters will show 
how to meet many of these problems through the widening 
influence of the public school, democracy's chief agency for 
permanent health improvement. 

^ Same report, p. 64. 



CHAPTER III 
HEALTH AND HEREDITY 

The Infinite Varieties of Traits in American Children. — 

Modern views of heredity in man start with the principle of 
the essential diversity of human beings in any mixed popu- 
lation such as the United States affords. Though there are 
countries, using the word in its broadest sense, in the Old 
World whose population is blue-eyed, others where all the 
people have curly or kinky hair, others where the nose is 
aquihne, others where practically all are tall, and so on, in 
this country all these physical traits are for* the most part 
much mixed together. It is because the population of this 
country is so greatly hybridized that the people are so differ- 
ent. It follows, first of all, that there are few rules that hold 
for all people. A neglect of this fact is in part responsible for 
the failure of works on pedagogy, or hygiene, or medicine, 
to command universal respect. We learn that the child's 
mind works so and so, in face of the fact that *'the child" is 
an abstraction; we are taught how to care for the teeth, 
despite the fact that *'the teeth" are a mythical thing; and 
we learn of the prognostication of *' typhoid fever" as though 
it were a definite phenomenon that needed only to be seen 
to be recognized, instead of the different kinds of behavior 
of various living human bodies to the parasite that is called 
bacillus typhosus. 

As I have said, the child-mind is a pure abstraction. Actu- 
ally we have the minds of various children which are, in the 
extreme, so unKke that they have few features in common. 
Nor does it help much to divide them into the feeble-minded 
and the normal, or the wayward and the normal, for "the 

45 



46 EDUCATIONAL HYGIENE 

normar' is itself a scholastic and pedantic figure of speecli 
and does not, strictly speaking, correspond with anything 
found in nature. The teacher who relies solely upon what 
he has learned from the books about the child's mind will 
be far less successful than the teacher of common sense 
who has had a wide range of experience with children's 
minds} 

Similarly, the instructions as to the care of ^Hhe teeth" 
are of comparatively Httle use to certain races, notably West 
African negroes, whose teeth are highly resistant to caries, 
and their faithful appHcation will probably do little to delay 
the ravages of decay in the teeth of those who are non-re- 
sistant. How often may one hear of a white person who has 
not lost a tooth in his head and had never been to a dentist 
and makes little or no use of a tooth-brush. On the other 
hand, you will frequently find those whose constant use of 
antiseptic tooth-washes does Httle to stay the rapid loss of the 
entire set. It has even been contended that {a) were there 
no tooth-brushes there would be no more caries than at pres- 
ent, (h) tooth-powder is the real cause of the weakness of our 
teeth and water only should be used, and (<;) the use of a 
bristle brush is in the highest degree unnatural and is one of 
the leading causes of tooth decay! Most other ^'laws of 
hygiene" are similarly disputed. The fact of this difference 
of opinion is mute testimony to the fact that individual dif- 
ferences are not less important, probably much more im- 
portant, than hygienic conditions. 

Similarly in respect to typhoid or other diseases, what the 
reaction of the body to any toxin of a parasite or other un- 
toward condition working on the body is, depends, within 
limits, far more upon the constitution of the individual than 
upon the chemical composition of the toxin, and the partic- 
ular untoward condition. 

This, then, is the first lesson of modern biology: Health is, 
within limits, more a matter of heredity than anything else and 

1 See Thorndike's " Individuality." 



HEALTH AND HEREDITY 47 

in so far as hygiene fails to take this fact into account it fails 
to he of high practical value. 

Accounting for Individual Differences. — Recognizing then 
the fundamental importance of individual differences, it is 
for us to account for them. Now, no person who is an agri- 
culturist will deny the importance of good conditions of 
development upon the matured organism. Proper food, 
protection from extreme environmental conditions, from com- 
petition, from parasites, and from gross accidents, are impor- 
tant for any crop of corn or calves; so it is with man. But 
if under good culture I fail where my neighbor succeeds I 
must look to my seed or ^^ strain." His potatoes were rot- 
resistant; his corn was from a ^Mry-f arming" strain; his 
hogs were cholera-proof, etc. The agriculturist knows that, 
given certain fundamental conditions of culture, the differ- 
ence of 3deld depends chiefly upon the hereditary nature of 
the organism. And we shall find that these hereditary qual- 
ities so reappear in successive individuals and generations as 
to warrant us in speaking of this succession of similarly en- 
dowed individuals as constituting a ^'biotype." Individuals, 
then, are different largely because they belong to different 
biotypes. 

We have next to consider how these differences that 
distinguish one biotype from another become disseminated 
throughout the entire population. This is the subject of 
heredity in its narrow sense. And to understand this sub- 
ject we must clear our minds of a lot of intellectual rubbish, 
figures of speech, and mystical ideas. Many persons would 
say that we inherit traits from our fathers and mothers. 
Strictly, we do nothing of the sort. It is just as true, in 
one sense, that a father inherits certain of his quaHties from 
his son. The fact is that neither inherits from the other any 
more than the youngest leaf on a growing shoot inherits its 
shape from the next older one. The leaves are alike, to be 
sure, but they are ahke because they inherit in succession 
from the same common stuff, located in the twig at the tip. 



48 EDUCATIONAL HYGIENE 

This common stuff we may call the germ plasm. It is be- 
cause the successive leaves on a twig are developed out of 
the same germ plasm that they are alike. It is because 
father and son are developed out of the same germ plasm 
that they are alike. The case in man is more complicated, 
however, in that a loss of materials and an addition of other, 
foreign materials is made to the germ plasm at the initia- 
tion of each new individual in the processes called matura- 
tion of the germ cell and fertilization or union of gametes, so 
that strictly the son is only a younger half-brother to his 
father by a different mother. We have got used to think- 
ing of the eggs in the mother as hers. Strictly they are not 
hers but are merely a part, left behind, of the fertilized egg 
out of one part of which she developed. The rest was car- 
ried in her body, protected, warmed, and fed by that body 
and put in the way of continuing its history, reaching back 
to the beginning of life on the globe, provided that *' fertili- 
zation of the egg'' can be secured. 

When we think what a history that germ plasm has had, 
through what billions of accidents of not being continued it 
passed unscathed to the present day; when we consider how 
its continuation is absolutely determined by our behavior; 
when we contemplate the wrong that we should do society 
and the world if, through our neglect, an excellent germ plasm 
should not be continued for another generation, then we 
realize dimly the magnitude of the trusteeship that is ours in 
the care of this germ plasm that we carry. Then we realize 
the heinousness of the crime of poisoning it with alcohol, 
or of rendering it impotent through the access of venereal 
disease, or of preventing its continuation because, forsooth, 
we don't want to be bothered with the care of the new soma 
that might arise from it and so continue this germ plasm to 
the next following generation. The germ plasm belongs to 
society, to the state, and to injure it or to prevent it from carry- 
ing out its manifest destiny, save for eugenical reasons, is to 
be unfaithful to one's trusteeship, is to commit a crime against 



HEALTH AND HEREDITY 49 

society and the state; and it should be so considered by the 
state.^ 

Again, strictly, we do not inherit characteristics from the 
germ plasm. It is only a figure of speech when I say I in- 
herited my nose. There was no nose in the germ plasm. 
The germ plasm carried some things that determined that I 
should have such bones and cartilages and connective tissues 
as give the form to my nose. These materials in the germ 
plasm we call determiners; and it is because of some difference 
in the determiners for the nose in my germ plasm from the 
nose determiner of your germ plasm that I have a different 
form of nose from you. The peculiarity of the nose determiner 
in my case depends upon certain differentials in the determiner. 
Noses, then, have their distinguishing characters largely, if 
not chiefly, by virtue of certain differentials in the germ plasm. 
We have our hereditary peculiarities because of the. persist- 
ence, through the stream of germ plasm that passes down the 
generations, of certain differentials. 

Environmental Modifications of Determiners. — We in- 
herit, as we have seen, determiners. The determiner is not 
the characteristic; it must develop to produce the character- 
istic. Now, the course of any development is not definitely 
predetermined, but depends upon surrounding conditions. 
Here is where environment plays its important role in modi- 
fying the development of the determiner. All efforts for care 
of the pregnant woman, of the expectant mother, all child- 
feeding, milk-station work, all parental training, all school 
instruction, religious influences, and cultural conditions in 
general are brought to bear to secure the best possible develop- 
ment of the determiner of the various elements of the phys- 
ical, intellectual, and emotional make-up. Good culture can 
do much to insure the full development of determiners in the 

1 "Original nature comes from original nature: inheritance is from germs 
to the germs. Long before a man is born, the germ-cells that will thirty years 
later produce his children are set off apart. They do not come from him as a 
collection from his total make-up, but from the germs that produced him." 

— Thorndike, in " Education," p. 206. 



50 EDUCATIONAL HYGIENE 

fertiKzed egg; bad conditions may prevent the full develop- 
ment of determiners; but the best conditions cannot cause to 
develop in a child any trait the determiner for which is ab- 
sent, just as rain and sunshine and manures do not cause a 
plant to arise where no seed has been planted. Here is the 
clear limit to the power of environment. 

The Combinations of Determiners, — Finally, each child is 
derived from the union of two germ plasms — of two bundles 
of determiners — from two germ cells. In the two bundles 
that unite there are many determiners that are the same, but 
there are probably some that are found in one of the germ 
cells and not in the other. When both germ cells bring to the 
embryo a determiner for the same trait, the trait may be said 
to be duplex. When only one germ cell supplies the deter- 
miner for a trait, the trait in the developed soma is simplex. 
If neither parent supplies in his germ cells the determiner for 
a trait, then the trait does not develop in the offspring. 

When the determiners are duplex in the individual, then, 
when that individual forms his ripe germ cells, every one of 
them contains the determiner for the trait. When an in- 
dividual is simplex in this respect, then, when the germ cells 
are formed in such an individual, half of them possess and half 
of them lack the determiner. If the individual has acquired 
from neither parent the determiner for the trait, then in none 
of the germ cells of that individual will a determiner be found. 

This abstract conception may now be illustrated by an 
example, and I choose that of eye color, (i) When both 
parents are brown-eyed and belong to brown-eyed stock, so 
that all of their germ cells carry the determiner for brown 
iris pigmentation, then all of the children that arise by the 
union of such germ cells will have the determiner for brown 
iris pigmentation duplex. (2) If one parent be brown-eyed 
and of brown-eyed stock, whereas the other is brown-eyed 
but simplex, then all of the children will have brown eyes 
but half of them will be duplex and half simplex in this re- 
spect. (3) If one of the parents be duplex brown-eyed and 



HEALTH AND HEREDITY 5 1 

the other blue-eyed, then all of the children will be brown-eyed 
but simplex. (4) If both parents be simplex brown-eyed, 
then one in four of the children will be duplex brown- 
eyed, two simplex brown-eyed, and one in four will be blue- 
eyed. (5) If one parent be simplex brown-eyed and the other 
blue-eyed, then half of the offspring will be simplex brown- 
eyed and half blue-eyed. (6) If both parents be blue-eyed, 
then all of the children will have blue eyes. 

Health and Heredity. — We are now in a position to take 
up the relation of heredity to health. In treating- of this 
topic I propose first to speak of the relation of heredity 
(i) to the physical development of the child, (2) to the mental 
development, (3) to its moral development, (4) to its resist- 
ance to physical disease, (5) to its resistance to mental disease, 
(6) to longevity?- 

(i) Physical Development and Heredity. — Inat the course 
of development of the body has a hereditary basis is obvious 
from a vast number of family histories that have been studied. 
The methods of inheritance of defects in physical development 
are of three types so far as known. There are defects due to 
an extra determiner, those due to the absence of some deter- 
miner that is typically present, and those that are sex-linked. 
{a) Physical Defects Due to an Extra Determiner or Deter- 
miners. — To this category belong certain eye defects. Of 
these, juvenile cataract is one of the commonest and most 
important. This consists of a clouding of the lens of the eye 
and has a pedagogical importance because it interferes 
greatly with vision and eventually causes practical bUndness. 
This may begin to appear at birth. Nettleship describes the 
case of a boy who showed a cataract when the eye was first 
carefully examined, three months after birth. Usually, how- 
ever, it begins later, at eight, ten, fifteen, or twenty-five years, 
or even later. If now the family history be studied, it will be 
found, practically invariably, that one parent of the affected 

iSee Davenport's "Heredity in Relation to Eugenics," and Rosenau's 
" Preventive Medldne and Hygiene." 



52 EDUCATIONAL HYGIENE 

child had also cataract in youth, and this can often be traced 
back for several generations without a break. Unaffected 
descendants of affected ancestors do not have affected off- 
spring. 

Among other eye diseases that fall in the same category 
are: glaucoma, or the distension of the ball of the eye by 
excessive production of internal fluids; retinitis pigmentosa 
(usually), which is a degeneration of the retina that leads to 
irremediable blindness; and night-blindness, often associated 
with the foregoing, which makes it hard to see by artificial 
light. 

Imperfections in the development of the male genitalia 
fall into the category of positive imperfections to develop- 
ment; in extreme conditions the individual is a ^'hermaph- 
rodite," and may show psychical conditions as ambiguous as 
his physical. Finally, nearly all abnormalities of fingers and 
toes seem to belong to this group, including polydactylism, syn- 
dactyhsm ('' lobster-claw"), brachydactylism (or two-jointed 
fingers), double-join tedness of fingers, and crossed or hammer 
toe. The affected persons tend to reproduce their peculiarity. 

{b) Physical Defects Due to the Absence of a Determiner. — 
One of the best examples of this class is defect of pigment, as 
seen in albinos. This condition is usually complete; the 
spotted condition is rather rare and is properly not albinism, 
and seems to be inherited as a positive character. When pig- 
ment is lacking the hair is, including that of the eyelashes, 
white; the skin is of a clear, translucent pink; the retina is 
devoid of pigment, so, as seen through the pupil, the back of 
the eye looks pink; even the blue of the iris may be absent. 
Such cases usually arise from consanguineous marriages, be- 
cause the defect has to be carried in each of the fused germ 
cells. 

In addition to albinism there is some reason for believing 
that excessive growth in stature, congenital deafness, and 
cleft palate are developmental defects that are due to the 
absence of each of one or more determiners; but it must be 



HEALTH AND HEREDITY 53 

admitted that heredity in these cases seems to be complex 
and has been insufficiently analyzed. 

(c) Physical Defects Due to the Absence of a Sex- Linked 
Determiner. — ^Here belongs, first of all, hemophiha, or inabihty 
to coagulate the blood after a wound. The so-called "bleed- 
ers" are apt to die in consequence of excessive hemorrhages; 
so that this defect is a very serious one. As in the case of 
other sex-limited quaHties, it is found typically only in males 
and only such as have unaffected parents, but the trail of 
the defect can be traced through the female line to some 
affected male ancestor. No affected male who marries a 
normal woman has any affected children, but the daughter 
of such will have half of her sons affected. Atrophy of the 
optic nerve and multiple sclerosis are other examples of this 
trait. 

(2) Mental Development and Heredity. — Heredity plays 
a great part in the mental development of the child also; 
typically by the absence of one or more determiners for com- 
plete mental development. Thus, there is much evidence that 
hereditary imbecility is due to the absence of one or more de- 
terminers; for two parents of the hereditary-imbecile t3^e 
have t3^ically, if not always, only offspring of this type. In 
the same way hereditary epilepsy seems to result from the 
absence of a single determiner that regulates the centres that 
control movements. Cerebral palsy of infancy is similarly 
due to a defect. Finally, color-blindness must be mentioned 
as a type of the sex-linked characters that belong to this 
category and whose inheritance follows the same law as 
hemophilia, mentioned in the last paragraph. 

(3) Moral Development and Heredity. — Heredity has 
important relations to moral development. Studies of way- 
ward children have shown that bad temper, especially of the 
stormy, outbursting kind (tantrums), is clearly dependent on 
a positive determiner; the trait passes without break from 
generation to generation. Also extreme eroticism, eroto- 
mania, is inherited in similar positive fashion. Many other 



54 EDUCATIONAL HYGIENE 

elements of wayward, violent, and criminalistic behavior 
have a clear hereditary basis, even though the exact method 
of inheritance cannot yet be given. 

(4) Resistance to Disease and Heredity. — Inheritance of 
resistance or susceptibihty to disease has long been recog- 
nized, but since the grand developments in bacteriology the 
old theory of diathesis (predisposition) has rather fallen into 
disrepute; but it is now reviving again. Just as the organs of 
the body are not in the germ plasm as such but merely de- 
terminers or differentials of them, so with respect to disease. 
Susceptibility as opposed to resistance is due to one or more 
differentials in the germ plasm. 

In some cases this susceptibihty is due to a positive de- 
terminer. Thus the tendency to form fluid-filled vesicles in 
the skin after the sKghtest provocation such as a pressure or 
a scratch (epidermolysis bullosa) is a trait that shows itself 
in the first month of Hfe and it is strongly hereditary. It is 
to be noted that the bullae are not formed without the trauma; 
they are the reaction of a specially susceptible skin to a sHght 
trauma. Similarly a tendency to chronic jaundice runs in 
certain families without skipping a generation. 

In other cases, and these seem to be commonest of all, 
the susceptibility is due to an absent determiner. To this 
class belongs in all probabihty non-resistance to tuberculosis, 
and to the causes that lead to catarrh; here also, almost cer- 
tainly, susceptibility to cancer. Thus lack of resistance plays 
a role of the profoundest importance in some of our worst 
diseases. 

(5) Resistance to Mental Disease and Heredity. — In 
speaking of mental breakdown we are prone to find its cause 
in some sort of stress, loss of a close relative, disappointment 
in love, failure in business, etc. But these things happen to 
many people who do not lose their mental vigor. Those 
who thus give way have some neural defect, some lack of 
mental strength. That juvenile dementia is due to an actual 
lack of some determiner is indicated by its method of inherit- 



HEALTH AND HEREDITY 55 

ance. If both parents be subject to it, all of the children are. 
There seems to be a little more doubt about the conditions 
that are classified as manic-depressive. 

(6) Longevity and Heredity. — That longevity has a he- 
reditary basis cannot be doubted. It is easy to find frater- 
nities, even of large size, nearly -all of whose members have 
lived to be over eighty years of age and in which both parents 
and at least half of the grandparents had reached the same 
advanced age. In other families, on the contrary, most if 
not all are dead by fifty years. We can understand this 
upon the principle of inherited resistance to specific diseases. 
A body that is resistant to tuberculosis, to catarrh of the 
respiratory tract, and to cancer passes unscathed through 
the most dangerous period of beginning decline of the bodily 
powers. 

The foregoing list by no means completes fhe roll of mor- 
bid, or contrariwise healthy, conditions that have a hereditary 
basis, hut only those whose method of inheritance is best known. 
Many, if not most, serious heart troubles that date from 
early childhood are due to hereditary malformations or bad 
positions of the heart. Harelip and cleft palate, multiple 
nipples, hereditary ataxy, Friedrich's disease, amaurotic family 
idiocy, certain edemas, various disorders of metaboKsm, 
rheumatism, migraine, dipsomania, and scores of other con- 
ditions have a clear hereditary factor; and, conversely, the 
absence of these is largely due to some hereditary source of 
strength and vigor. An early breakdown can usually be 
attributed to some weakness in the machine. 

Eugenics and Health. — The wide-spread absence of phys- 
ical and mental health in the population is a tremendous 
handicap to society. Our States spend over $100,000,000 
annually in the care of the defectives and the sick, and it 
may be conjectured that no less a sum is lost privately 
by illness of one sort and another, due to inherited lack of 
resistance. Not only is there a huge money loss but a loss of 
labor of an army of effective persons caring for defectives 



56 EDUCATIONAL HYGIENE 

who might otherwise be engaged in some constructive work. 
The consideration of all of these facts has led many persons 
to urge that attempts be made by education and by state 
interference to diminish the heavy reproduction of these 
mental and physical weaklings. This is the practical applica- 
tion of eugenics, which on its theoretical side is largely the 
study of heredity in man. 

While it is recognized that the state, by segregation of 
those unfit to reproduce, or even by sterilization, may di- 
minish the reproduction of the grossly unfit, many have grave 
doubts if, by education, anything can be done to influence 
marriage selection. In this doubt the present writer does not 
share ; and the reason for his optimism is that scores of per- 
sons who are thinking of marrying, others who are interested 
in another, and still others who are so deeply in love that 
they declare they will die if their love is not satisfied, have 
written to him to know if the contemplated union will prob- 
ably result in healthy offspring. And in two cases, at least, 
on viewing the facts of heredity as displayed by a graphic 
representation of their own statements, the proposed marriage 
has been abandoned. These cases were, to be sure, those in 
which there was home opposition on eugenic grounds and the 
writer was called upon to act as referee. I mention these 
facts as justification for my contention that at an early stage 
in the often prolonged process of falling in love proper in- 
struction may avert an impending ill-advised match. One 
great difficulty has been that our knowledge of the inherit- 
ance of traits is wofully deficient.^ 

As an instrument of research in human heredity and 
eugenics there was founded in October, 1910, by Mrs. E. H. 
Harriman, at Cold Spring Harbor, Long Island, N. Y., the 
Eugenics Record Office. This office seeks to fill the need of 
a clearing-house for data on human heredity, and a place 
where studies on heredity can be made. This office seeks to 

iSee chapter on "The Hygiene of the High School," in Johnston's "The 
Modern High School," by the editor. 



HEALTH AND HEREDITY 57 

interest persons in their own family history by distributing, 
without charge, a schedule called ''Record of Family Traits" 
to those who agree to fill it out for their own family and return 
it to the office — a second copy being sent to such as desire 
to retain it for their own use. In this way thousands of per- 
sons have had their attention directed to a careful considera- 
tion of their own traits and the distribution of these traits 
throughout their family. 

The application of such family histories is very varied. 
Many teachers have suggested that every pupil on entering 
a school should bring with him, filled out, such a schedule so 
that his teachers might have some knowledge of his hereditary 
background; might have some notion of the probable poten- 
tiahties that they are to cultivate. Every teacher learns, 
usually at the end of the semester, about his student's capac- 
ities, but it would save much valuable time if* he had some 
inkhng of this at the very beginning. A knowledge of the 
heredity of pupils will, of course, be indispensable in any 
scientific plan of vocational and hygienic guidance. Similarly 
the family history would be of great advantage to the gym- 
nasium director in prescribing exercises for any student, and 
it would be useful in the infirmary in case the student should 
fall ill. A proper recognition of the facts of hereditary poten- 
tialities would be of assistance in all aspects of a student's 
training. 

To facilitate the inquiry as to the desirabihty of a given 
marriage from the standpoint of health of the children, the 
Eugenics Record Office distributes a schedule called "Index 
to the Germ Plasm," in which may be recorded parallel 
records of the young man and the young woman. Such a 
parallel record brings into clear relief the family inheritable 
traits and enables the expert to say at least something about 
probable traits of children. The schedule is a somewhat diffi- 
cult one to fill out, but already scores have been filled out 
very carefully and served as a basis for a clear statement of 
probable results of the given combination in so far as the 



58 EDUCATIONAL HYGIENE 

nature of the germ plasm is truly and fully set forth in the 
schedule. 

By such means, then, the health of the next generation 
may be made better than that of this — not merely by curing 
the sick, not merely by following the ''rules of hygiene," 
but by breeding a larger proportion of children who shall be 
in the less need of the rules of hygiene because their bodies 
are, by nature, highly resistant to health-destroying agencies. 



CHAPTER IV 
THE HOME HYGIENE OF CHILDREN 

Parents' Health Responsibilities. — In the past it has been 
a too common habit to lay the blame for the production of 
many of the physical and mental handicaps of children upon 
the public schools. A closer study of actual conditions, how- 
ever, reveals the fact that the home plays a far greater part 
than the school in the production of such handicaps. With- 
out the close co-operation of home and school little of real 
value can be developed in the way of improving the health 
conditions of school-children. In this chapter; an attempt 
will be made to outHne those points which parents need to 
understand to co-operate successfully with the school in the 
physical improvement of children. Parents greatly need to 
learn correctly to interpret the rather plain signs of common 
disorders in children. 

There are many significant habits which indicate such 
disorders, yet these are frequently either quite ignored or 
misinterpreted. Then the parent must also remember that 
symptoms of health are at least as important as those of 
disease, and that many things which to some seem abnormal 
are merely normal manifestations in the development of the 
child. Each individual child requires special study, for there 
is really no such thing as an average child. ^ All children are 
in one sense "exceptional." 

Wise parents should not make the common mistake of 
attributing many symptoms to one cause, but should often 
look and expect to find several such causes.^ 

* See Thorndike's book on " Individuality." 

2 Parents will find much help in Professor Ditman's little one-volume cyclo- 
pedia on "Home Hygiene and the Prevention of Disease" (DufiSeld). 

59 



6o EDUCATIONAL HYGIENE 

Heredity. — ^As Doctor Davenport has shown, the matter 
of heredity is of such paramount importance in any serious 
study of children that it deserves some discussion before all 
else, and this is of special interest in respect to a considera- 
tion of nervous children. Very often the child is blamed both 
at school and at home for matters which are either the direct 
or indirect results of heredity and for which the child is little, 
if at all, responsible. 

In the home study of the child, parents can do no better 
than to commence with a careful consideration of those qual- 
ities which they themselves possess. Such an inquiry often 
unfolds and explains problems which otherwise might re- 
main unexplained, and which would therefore be difficult to 
correct. 

The child is a small mosaic of all his ancestors, but par- 
ticularly of his more immediate ones, and it is of the utmost 
importance to understand as far as may be just what ele- 
ments enter into his make-up. Why parents should so fre- 
quently ignore the rather plain manifestations of their own 
undesirable qualities when they appear in their children in a 
slightly disguised form is a matter hard to comprehend. 

"It is difficult to understand,'' says Doctor Leonard G. 
Guthrie, ",why a subject so important to the welfare of the 
community as the study of children should have been so 
long neglected," and one might add that it is still more diffi- 
cult to understand why a subject so important as the study 
of parenthood suffers from yet greater neglect. 

In the schools to-day we hear and see much of the nervous 
child, but how often is it understood that such nervous, and 
usually irritable, children have in most instances nervous, 
irritable fathers or mothers? The correction of nervous dis- 
orders in children ought often to begin with parents, for even 
with a bad heredity in this respect much good may be accom- 
pKshed if the child can be relieved of what is nearly always 
present under such conditions, namely, an unstable, neurotic 
home environment. But before parents can successfully study 



THE HOME HYGIENE OF CHILDREN 6 1 

their own nervous tendencies it is often important to recognize 
the early nervous manifestations of their children. 

Description of the Nervous Child. — Doctor Francis 
Warner, in his ^' Study of Children/' has briefly described the 
nervous type of child perhaps better than any one else, when 
he says: 

There is a class of children commonly met with in every commu- 
nity, termed nervous children. Such are apt to complain of headache, 
are difficult to put to sleep, they talk at night, and grind their teeth, 
while in the morning they are tired and not ready for breakfast. They 
are often bright enough mentally, and affectionate in disposition, but 
they are likely to be irritable, passionate, and too emotional. They 
are the children who are delicate without having any definite disease; 
they are rarely laid up with a definite illness but they are not strong; 
they cannot walk far without getting tired; some days they are too 
tired to do anything and must rest; capricious in appetite, yet some- 
times ravenous, but remaining stationary or increasing slowly in weight. 

The general balance of the body, as the child stands, is usually 
asymmetrical, with the head slightly drooped and inclined to one 
side; while the spine is perhaps bent a little to one side, with unequal 
shoulders, and the feet unequally planted. 

The eyes wander much, in place of being directed to objects. 
In the face the expression may be somewhat diminished, with ful- 
ness under the eyes indicating fatigue. 

When the hands are held out in front, asymmetry in balance of 
the arms is frequent, the left hand usually being held lower. The 
fingers frequently show twitching movements, if they are held separate 
from one another so as to be free to move. 

In mental habit such children are usually quick in learning, talk- 
ative, playful, and often laughing. 

In social life they seek one another's company and as they are usu- 
ally imitative, one may prove a source of mental excitement to another. 

On looking further at such a child, you will probably find that 
the face is the best nourished part of the body. The limbs are thin; 
the teeth are very likely flattened at their tips from the constant 
habit of tooth grinding. 

These nervous children are very difficult to feed: the appetite is 
either very poor or it is capricious. 

We may further add to this accurate description of Doctor 
Warner's by stating that nervous children are often restless, 



62 EDUCATIONAL HYGIENE 

inordinately active, busy to no very definite purpose; their 
emotional natures are often unduly developed, and under 
very poor control. Laughter and tears are always near the 
surface. Affection, anger, sorrow, and joy are not very well 
differentiated. They are inclined to selfishness, fond of at- 
tracting attention, quick to give offense, but quicker to re- 
sent it in others. At home children of this type are usually 
very badly disciplined, and indeed such children often furnish 
a pretty fair index to the character of one or both parents. 
Such parents probably use very Httle discretion in matters 
of discipHne. They cannot bear to see the child suffer and 
consequently, since it rarely meets with resistance, it wishes 
to have everything it sees. It wants every whim and caprice 
satisfied. Such a child soon becomes a perfect young tyrant, 
and he is not only a source of annoyance to others but he 
defeats his own happiness also, for he never learns the habit 
of self-control. Most of the neurasthenic adults who go 
about in the search for unearned happiness have passed through 
a childhood similar to that just described, and indeed we may 
safely state that their nervous disorder is often largely the 
direct result of faulty early methods of training. Nervous 
children need definite and rigid, but at the same time kind, 
home discipline, and in many instances such training might 
well begin with one or both parents. 

"Such children,'^ says Doctor I. A. Abt, "should be taught 
to endure pain with some degree of self-control, to respect the 
rights of others, to obey just commands, to acquire some de- 
gree of composure, to five regular fives, to be unselfish, and 
to love the good, the true, and the just. Particularly high in 
these quafities is the love of truth. He who is true to himself 
and others is rarely overtaken with a disorder whose striking 
characteristics are exaggeration and dissatisfaction.' ' 

Environment. — It is a difficult matter always to draw a 
sharp line between the influences of heredity and those of 
environment, for such influences are constantly overlapping. 
Even a child with an originally well-balanced nervous system 



THE HOME HYGIENE OF CHILDREN 63 

may well become irritable and generally unstable through the 
influence of a bad nervous environment. On the other hand, 
many a child with a faulty heredity or a distinctly nervous 
predisposition has developed into a normal life through the 
influence of a favorable environment. Environment has much 
to do with deciding the character and stability of the child. 
It acts every hour of the day, tending to form the habits, 
lines of acting, and modes of thought. 

Parents control the bodies and minds, hearts and souls of their 
children, not only through hereditary traits handed down from their 
ancestors, but also by what they themselves do and think. 

Example and imitation guide the child in thought and action.* 

A bad school environment is capable of doing much harm 
to any child, but the best of school environments can do Httle 
to offset the constant and pernicious influence of an unwisely 
conducted home. It is too much to ask of the school that it 
re-educate a child whose first five or six years of fife have run 
in wrong channels, or that it correct in a few hours each day 
the influence of daily faulty habits of the home. 

Children surrounded day after day by a home environment 
little or not at all adapted to character formation furnish 
most of the nervous pupils of our schools. 

Some Common Functional Nervous Disorders of Chil- 
dren. — Most of the nervous disorders of children are found 
in the child of neurotic temperament whose general character- 
istics have already been described. 

These disorders are usually one or more of the following 
group : 

{a) Habit spasms. 

(h) Chorea. 

{c) Stammering and some other speech defects. , 

{d) Morbid fears. 

{e) General nervous fatigue. 

In a discussion such as this, which of necessity must be 

* Oppenheim. 



64 EDUCATIONAL HYGIENE 

strictly limited, it will only be possible very briefly to outline 
a few of the leading symptoms in each of the groups men- 
tioned, with the expectation that the parent, after recogniz- 
ing the situation, will seek proper medical aid. 

Habit Spasms. — These are characterized by quick, invol- 
untary, peculiar movements. They may be easily recognized 
by the following description by Guthrie: 

A series of lightning-like blinks or nods or sudden turns of the 
head aside. The eyebrows may be elevated or corrugated or the upper 
lids may be raised several times in quick succession, as in a munching 
rabbit, or the nose may be wrinkled and the nostrils expanded or con- 
tracted, whilst half a dozen or more little ineffectual sniffs are pro- 
duced, or a variety of grunts and queer guttural noises are heard. 

The characteristic of all these simple tics is that they suddenly 
come and go, and each form will commonly give place to another. 
It is seldom that more than one trick or antic is present at a time. 
In a more complicated form of habit spasm or tic the child will often 
perform the most astounding tricks. 

Such habit spasms seem often to be a family habit and 
no doubt usually represent a neurotic family temperament. 

Scolding, nagging, or punishment on the part of parents 
only serves to increase this trouble in a nervous child, and 
prompt advice should be sought from a competent physician. 
The habits are usually curable under proper conditions. 

Chorea. — Chorea, or St. Vitus's dance, is often confused 
Vvdth habit spasms, and this is most unfortunate, as it is of a 
much more serious nature. 

It ought to be recognized early, but as a matter of fact 
it is seldom recognized by parents and teachers until it is 
well advanced. 

Any child should be suspected of chorea who has some or 
all of the following habits: 

(a) Extreme restlessness. 

(b) Purposeless motions. 

(c) Inability to hold pencils, books, knife, fork, etc., 
securely. 

{d) Falling down or stumbling easily and frequently. 



I 



THE HOME HYGIENE OF CHILDREN 65 

The spasmodic symptoms include muscular spasms of 
various parts of the body, such as contortions of the face, 
jerky movements of the head, shoulders, arms, and legs. In 
general, the muscular spasms include larger groups of muscles 
than in habit spasms. 

The trouble is often, If not always, closely associated 
with diseased tonsils and rheumatism, and in many instances 
the heart is affected. 

Early and systematic treatment is required, and the child 
should be removed from school both for his own good and 
for the good of other pupils, some of whom are very likely to 
imitate the grimaces and other habits until it becomes a more 
or less fixed habit on themselves. 

Children with this disorder require rest in bed, quiet, 
regular life, nourishing food, and proper medical treatment. 

Stammering and Stuttering. — Stammering, which is caused 
by a *' spasmodic arrest of utterance," and stuttering, which 
consists in *' spasmodic repetition of initial syllables," are 
both often associated with, if not caused by, a neurotic tem- 
perament. The basis of these speech defects lies in '' defective 
nervous control." ^ 

Doctor Still states that the determining cause may be 
some depressing illness, or a shock, or some form of physical 
irritation. Sometimes it appears after diseases such as scarlet 
fever, diphtheria, or whooping-cough. Fright may initiate 
the disorder, and so may an accident. In some cases it ap- 
parently originates through imitation. 

Most children who suffer from these defects of speech are 
of superior intelligence, and are usually sensitive and of 
highly organized disposition. 

The treatment of speech defects requires special attention 
unless they are quite mild in nature, and specialists should 
therefore be consulted. 

Above all, it should be remembered that nagging, scold- 
ing, or fault-finding in the cases of children who stammer or 
stutter will produce great injury to the child. 

» See Bibliography. 



66 EDUCATIONAL HYGIENE 

As Professor Terman well says, "the stuttering child 
presents a tragedy to which a majority of teachers and parents 
are strangely blind, and at home the onset of the disease is a 
signal for impatience and reproof on the part of parents. 
The result is often the formation of morbid habits of thought 
and failure in school work.^^ 

Morbid Fears. — Nervous children are rather prone to 
morbid fears of various sorts, and in some instances these 
fears cau^e an intense suffering, little or not at all understood 
by parents. 

Doctor Guthrie well says that the earliest indications of 
fear should be recognized and should meet with sympathy, 
encouragement, explanation, and removal of its causes if 
possible — never with badinage or indifference. Of all emo- 
tions, he says, it is the one most calculated to produce lasting 
effects upon a neurotic child. 

These morbid fears include all sorts of things which the 
child is quite unable to explain. Often through shame he 
hides his fears until they become almost an obsession or a 
fixed idea. Many of the ^' queer ^' habits of children may be 
explained by these suppressed fears. Sometimes the child 
is made by them to appear stubborn, or he may develop un- 
truthfulness, embarrassment, or a variety of other peculiar- 
ities so often misinterpreted. 

Such fears include, among many others, fear of the dark 
to an extreme degree; fear of sounds such as bells, the wind, 
whistles, etc.; fear of space, of death, of sickness, of crowds; 
of future punishment, of stories of a grotesque or otherwise 
fanciful nature; fear of certain real people, or of witches. 
Some children develop fears of shadows, of the forest, of water, 
of Hghtning, or even of the most common and ordinary kinds 
of objects. Not infrequently rehgious fears develop in a 
sensitive child which fairly paralyze the joy of living. The 
normal child will not, in fact, be very religious, for religion is 

1 Parents and teachers may well read Terman's " The Hygiene of the School 
Child," and Hoag and Terman's ''Health Work in the Schools." — Ed. 



THE HOME HYGIENE OF CHILDREN 67 

to such children something quite beyond their childish com- 
prehension, and something in which they are therefore not 
much interested. An intense religious zeal in a child, as 
also in some adults, is in itself a symptom of a nervous dis- 
order, not an evidence of desirable piety. 

Corporal punishment is always of doubtful value, but in 
the case of nervous children, and particularly those with mor- 
bid fears, it must be unhesitatingly condemned. 

Unnatural remorse for youthful misdemeanors, real or 
imaginary, is often seen in nervous children, and an '' ex- 
treme anxiety to be strictly truthful" is again not an evidence 
of moral rectitude so much as of morbid nervous instability. 
Worry and apprehension are also sure signs, in children at 
least, of the neurotic temperament. 

In childhood many danger signs of future mental unbal- 
ance may often be discovered by those able* to interpret 
them, and through this discovery there may be avoided in 
many instances not only the neuroses of adults but also 
actual insanity. The prevention of insanity is at last coming 
to interest the public nearly as much as the prevention of 
other forms of disease. 

General Nervous Fatigue. — Fatigue is so common and is 
produced in such a variety of ways that a full discussion of 
it at this time is quite impossible. Parents should remem- 
ber that the normal child does not fatigue easily and that 
when he does tire he recuperates rapidly after sleep. 

The chronically fatigued child needs medical advice. 
Play and other physical activities are normal to the young 
and anything more noticeable than ordinary weariness in 
children calls for careful consideration. 

In real cases of fatigue there is an actual poisoning of 
the central nervous system through the absorption of fatigue 
poisons. 

As Woods Hutchinson says, "whenever the blood is im- 
poverished below a certain degree or becomes loaded with 
fatigue poisons or other waste products above a certain point, 



68 EDUCATIONAL HYGIENE 

then the nervous system proceeds to make itself felt. The 
practical point is that a fatigued child is a sick child and the 
cause or causes of such sickness must be discovered." 

Sometimes this is worry, or abnormal fears, or it may be 
due \o digestive disorders, or wrong food, or too little sleep, 
or various forms of nervous overpressure. But whatever 
the causes are, the child has a right to the protection from 
future troubles of the same sort which only a careful study of 
his case will afford. 

Common Errors in Children's Diet.^ — In children of the 
school age it is very common to notice those who are suffer- 
ing from some form of malnutrition. Such children usually 
have the following appearance: they are thin, pale, and nerv- 
ous; often the lymph glands of the neck are enlarged; some- 
times the gums and lining of the eyelids are quite colorless; 
headache is rather common, and either diarrhea or consti- 
pation is the rule. A careful history of such a case will usually 
bring out the information that the child is very capricious in 
appetite, that he has acquired fussy food habits; that he is 
irritable, and perhaps sleeps poorly or at least is restless at 
night. Not many of such cases have their basis in any very 
definite disease, although some are tubercular, as would be 
clearly demonstrated by the proper tests (Von Pirquet and 
others). 

These children are, in the majority of instances, accord- 
ing to the writer's rather extended experience, neurotic, and 
their fussiness about food is only one of many other nervous 
symptoms. 

Careful questioning brings to light the fact that the child 
will not eat the ordinary vegetables, with perhaps the excep- 
tion of potato; that he is inordinately fond of sweets; that he 
abhors fat, with the possible exception of butter. Sometimes, 
but less often, the child will eat certain vegetables in excess, 

* In the preparation of this section the writer acknowledges his obligations 
to Doctor Adele Jaffa and Doctor Langley Porter. See also the chapter on 
"School Feeding," by Doctor Bryant. 



THE HOME HYGIENE OF CHILDREN 69 

to the exclusion of meat or other forms of proteids, and often 
he will utterly refuse to drink milk. In the main, however, 
the malnourished school-child is addicted to excessive carbo- 
hydrates (starches and sugars), and consequently suffers from 
starch indigestion. This form of intestinal indigestion usually 
leads to headache, gas formation, diarrhea, or less often 
constipation. He is really a victim of one form of auto-in- 
toxication, or self-poisoning. With the cause or causes once 
discovered, the cure is often rather easy. It goes without 
saying that the fault is in many instances the parents' rather 
than the child's. Faulty food habits have been condoned 
if not actually encouraged, until the unfortunate child has 
become a victim of his vicious habits. Neither scolding, 
nagging, nor persuasion will avail much, but about the only 
reasonable course to pursue is for the parent t(^ learn what 
the proper diet is for a child at different ages and then see to 
it that he gets the diet suited to his needs. Place the proper 
foods before the child and then let him eat or go without. Or- 
dinarily these foods will consist of just what the normal 
adult members of the family eat, with the exception of tea 
and coffee.^ When such a child really becomes hungry he will 
eat good food of the usual varieties. Firm but kind and 
patient discipHne will always be necessary to secure satis- 
factory results. 

Eating between meals Is to be discouraged, at least until 
the child has established normal food habits. But once he 
has done so, there can be no valid objection to giving him 
real food when he is truly hungry. It must not be forgotten, 
however, that real food does not consist of candies and other 
sweets, and that in any case it must be given in reasonable 
moderation. As for water, neither child nor adult can drink 
too much, provided only that it is not taken to wash down 
unmasticated food. The proper mastication of food is a 
habit which should be acquired very early, but it will usually 
be observed that most children, malnourished as well as 

1 More than 50 per cent of school-children drink coffee, and often to excess. 



7© EDUCATIONAL HYGIENE 

others, need definite instruction in this respect. The ques- 
tion will naturally arise at this point as to what is the proper 
diet for children of different ages. To answer this question 
adequately would be quite beyond the limitations of this 
chapter, but as a very general guide the following suggestions 
'are given: 

For a Child Four Years Old. — The child is to have not 
more than three meals a day. Not more than one pint of 
milk should be given to drink, another pint may be given 
in the form of junket or custard or milk soup during the day. 

Breakfast. — ^An e^gg, with some thin ■ sHces of bacon; 
crisp toast and butter; some apple-sauce or stewed fruit or 
ripe fruit peeled; if the child is constipated, give honey, 
stewed prunes, or fruit jelly instead of butter on the toast; 
to replace some of the toast, give such cereals as Force, 
Shredded Wheat, Triscuit, or Toasted Rice Biscuit. 

Midday Meal. — Small portion of broth (veal, mutton, or 
chicken) or milk soup with vegetables pureed into it; small 
amount of simply cooked meat, no fried meat; at first, meat 
should be finely chopped and mixed with baked potato or 
boiled rice or fine Italian paste, upon which may be put some 
blood gravy or broth; white fish may be given occasionally; 
a green vegetable which has been put through a fine sieve, 
preferably cauliflower, green peas, green beans, spinach, or 
asparagus tips; crisp crackers or toast with butter. Dessert: 
plain pudding, or stewed fruit, or junket, or blanc-mange, or 
plain sponge-cake or stale lady-fingers with fruit juice. 

Supper. — Milk soup with some vegetables pureed into it, 
or some bread and milk, or junket, or custard; occasionally 
ice-cream may be given if it is of known quality. Milk jelly 
or egg jelly or fruit jelly made according to the recipe. 

Foods for Older Children. — ^After a child reaches the age 
of five he may ordinarily eat the same food as adults, if it is 
well selected, with the exception of tea and coffee. 

Desirable foods include: clean milk, well-cooked cereals, 
crisp bacon, fish, broiled steak, soups, soft eggs, thin toast, 



THE HOME HYGIENE OE CHILDREN 7 1 

bread and butter, corn bread, crackers, fruit of nearly all 
kinds, both fresh and cooked, especially baked apples and 
stewed prunes. Fat in some form is absolutely necessary. 
This is best taken in the form of butter or oUve oil. Often it 
is necessary to disguise the fat in some special palatable form. 

Undesirable foods include : fried meats, veal in any form, 
salt pork, tea, coffee, hot bread, doughnuts and hot cakes 
(except in strict moderation), all greasy foods, in general all 
fried foods. Bananas are rather hard to digest unless baked. 
Fruits with many seeds, such as raspberries and blackberries, 
are not desirable for young children. 

Meals consisting of a deficient variety must be avoided, 
such as coffee and bread, bread and syrup, potato and bread, 
or meals which include only starchy foods. There is no objec- 
tion to water with meals unless it is used to wash down in- 
sufficiently masticated food, but iced water is best avoided 
except in very hot weather. 

School-Children. — In considering the question of how 
best to feed school-children, it must not be forgotten that the 
period of school fife extends over a number of years, and that 
in the schoolhouse we invariably find children of different 
stages of growth and development and children with very 
widely different needs. It would be impossible for any di- 
rections, however lengthy, to cover properly or adequately 
the requirements of all children, even at the same stage of 
their lives, with their widely varying tastes and idiosyn- 
crasies and their special constitutional tendencies. No diet 
list, however carefully chosen, could be used with good results 
for all children of any one age, much less for children of all 
ages. 

The only hope of a proper solution to this many-sided 
problem lies in creating in the minds of those people who have 
the catering in charge, an intelligent understanding of the 
uses of the various foods, and trusting the rest to their dis- 
crimination. Many rules of dietetics are only of service 
when applied by the person who has had experience with 



72 EDUCATIONAL HYGIENE 

the particular child in question, and possesses a thorough 
understanding of its special needs. Only wide general prin- 
ciples are universally applicable. 

Kinds of Foods. — The scientific principles which underlie 
the proper selection of foods are few and easily understood. 
Chemical analysis has shown us that all foods, no matter 
how simple or how complex they may appear, contain only 
four classes of materials. Each class has many subdivisions 
containing an infinite variety of chemical compounds. But 
nothing has been found that cannot be classified under these 
four heads. Two of these are mineral matter and water, 
which are not necessary to consider in our present discussion. 
That leaves us only two main classes of nutrients to under- 
stand and to deal with — the nitrogenous group and the non- 
nitrogenous. 

The question is naturally asked: "Of what use is this 
classification? In what way does it help?" The answer is 
at once plain when we consider that these two classes have 
entirely distinct and separate offices to perform in the body. 
The protein or nitrogenous group builds tissues — the bones, 
muscles, nerves, internal organs, etc. It supplies material 
both for the building of new tissues, as in growth, and for the 
repair of the old. The non-nitrogenous group furnishes heat 
to keep the body warm and energy or power with which to 
perform our work. This material may be stored up in the 
body for future use in the form of fat, but can never be used 
to build real or deep tissues. Fat in the body is Hke coal in 
the basement, ready to be converted into heat and energy. 
Our need of it after we have accumulated enough fat to round 
out our frames is in direct proportion to the weather and to 
the amount of energy we expend in both voluntary and in- ■ 
voluntary functions. The Httle girl who sits in a warm room " 
and reads and sews does not need as much as her brother who 
plays ball in the cold winter air. 

That brother is the best example of a healthy creature in 
need of plenty of nourishing food, that we could well find, 



THE HOME HYGIENE OF CHILDREN 73 

especially if he is in his teens. There is every kind of a call 
for food that could be found under normal conditions. Who 
else in the family is growing so quickly, who else lengthen- 
ing out and widening every bond and tissue of the body? 
The baby of the family may be doing that, but she is not 
studying or exercising, neither is she under nerve strain. 
The father may be using his brain in his work and may be 
under nerve strain, but he is not growing and may not be 
exercising very much. Rarely indeed do we find a human 
creature whose demands for food materials are so many and 
so urgent as those of the boy in his teens. 

If the problems involved in the proper feeding of a grow- 
ing boy be solved first, the results may be modified for other 
children, up and down the line, according to their ages and 
conditions, and their individual needs. We have come to 
know a great deal about the food for the first period of rapid 
growth, that of infancy, since the chemical analysis of mother's 
milk has furnished us with a perfect model upon which to 
base our selection of substitutes when the natural food fails 
us. But the second period, that comes, early in the "teens," 
is not yet so generally understood. 

During these years of adolescence, when Nature is making 
every effort to develop and round out the perfect individual, 
she needs all the help we can give her. She cannot build if 
we do not supply her with material, but she can, and often 
does, build one part at the expense of another. It is a com- 
mon thing to hear a mother say, with reference to a child, 
that he "outgrew his strength." Translated, that expression 
means that the child did not get, or was not able to use, 
sufficient food material to supply the needs of the entire 
organism. 

It is the second and last chance that Nature has to remedy 
defects in the constitution, and she makes a desperate effort 
to accomplish it. The results of improper feeding at this 
time cannot be easily remedied. It is often a case of "now or 
never," and the work that is not done in this second formative 



74 EDUCATIONAL HYGIENE 

period of Kfe may not be done at all. Weak spots in the 
building will always remain weak spots, and we should not 
run any risks at this time. Many of the nervous symptoms 
usually observed during the period of adolescence are not 
necessary or normal. The nerves suffer from insufficient and 
improper nourishment, as well as from other wrong and un- 
hygienic conditions, during the early ^' teens." 

The Kind of Food Needed. — ^When the importance of 
proper nutrition is once fully realized, the first question asked 
is: *'How can we supply it — what kind of food does the 
child need ? " The answer is very plain. He needs all kinds, 
and in sufficient quantities. 

At first glance it may appear that no real directions have 
been given for the dietary of a growing child. ''Feed him 
everything. He eats everything now." But perhaps a second 
and more careful glance will disclose errors. True, there is 
no one great radical change advocated, but it is the accumula- 
tion of all the little things that makes the real difference. 
Nature works slowly. In order to help her we, too, must work 
slowly and patiently with carefully thought-out meals, con- 
scientiously persisted in for years, if we expect to see results. 
Some apparently slight change made in each meal three 
times a day for three hundred and sixty-five days in the year 
would make a great difference in the end. 

Suppose, for instance, it were decided to add "growing 
material to the dinner," other than the meat. Suppose the 
meat soup were replaced occasionally by a bean or pea soup 
or by one of the various milk soups, and that on other days 
the potatoes were replaced by rice or macaroni and peas 
used more frequently than other vegetables, and that on 
others the pie were replaced by custard or soft home-made 
candy, would not that alone make considerable difference at 
the end of the year? 

And if for breakfast oatmeal were used instead of wheat 
or wheat foods, breakfast cheese for those who do not eat 
meat or eggs, milk or cocoa instead of coffee, milk toast in- 



THE HOME HYGIENE OF CHILDREN 75 

stead of dry toast, etc., would not the sum total of the year's 
breakfasts count? 

The Lunch. — The meal that usually requires the most 
radical reconstruction is the lunch. Between the children 
that rush home and swallow a hasty bite of unsuitable material 
and hasten back for fear of being late, or else to play with 
the other children, and those who carry a cold lunch composed 
of food that would not furnish very much nourishment, even 
if it were not difficult to digest, there remain probably only 
a small percentage of children whose lunches are suited to 
their needs. This is a great drawback in many cases, for it 
is often the one meal where individual requirements can be 
most easily attended to. To sHght one meal out of three is 
to slight a very large portion of the child's opportunities for 
nourishment. ^ 

The limch can never be considered alone. It must of 
necessity depend largely upon what is given for the other meals 
of the day. It is really not a difficult task to make one meal 
complementary to the others when the habit of mind is once 
estabHshed. Having acquired a permanent mental picture 
of the food groups and knowing the special requirements of 
the child, it becomes an easy matter to arrange a lunch of 
nourishing materials not supplied by the other meals. 

Does he eat heartily of meat at night and perhaps have 
some for breakfast? The lunch should contain "non-meat 
protein." Does he prefer the vegetables and dessert at dinner ? 
Give him meat at noon. Do the other members of the family 
object to oil or fat? See that the growing boy gets peanut 
butter or mayonnaise sandwiches, etc., for his lunch. Is his 
breakfast Hght? His lunch should then be very hearty. Is 
he tired at dinner-time and sleepy ? His most nourishing meal 
should be at noon. Does he refuse eggs for breakfast? He 
may reHsh and digest them well for lunch, and thus it goes. 
It would be impossible to cover the ground of the various 
elements involved in the decision. 

In general, the lunch, as well as the other meals j should be 



76 EDUCATIONAL HYGIENE 

as simple as possible in order to supply the required nourish- 
ment. The work of handling the quantity and kind of food 
needed to build up the physical frame and keep the organism 
in good running order is quite enough strain on the digestive 
organs, without hampering them with unnecessarily compli- 
cated or difhcult dishes. As a rule, made dishes, fried food, 
"warmed-overs," smoked and salted meats, thickened gravies, 
etc., should not often be given, even to the healthy child, and 
never to one whose digestion is weak. Food that is difficult 
of digestion may often be handled perfectly on occasions, when 
frequent repetitions would cause disastrous results. It must 
never be forgotten, in this connection, that "what is one 
man's meat is another man's poison," and careful observation 
is the only sure guide. 

Main Points of Feeding. — The main points to keep in 
mind may be summarized as follows: 

Be persistent in using foods from each group. 

Be sure to use plenty of "growing material" without go- 
ing to an extreme with meat. 

In using meat substitutes remember: 

{a) That milk is the most valuable one to use if it agrees, 
and that skim-milk is just as rich in growing materials as 
whole milk. 

(&) That eggs come next in order. 

{c) That nuts must be ground or very well chewed in order 
to be properly digested and assimilated. 

{d) That soup meat has all the growing material left in 
it, and none of the deleterious elements, and is a cheap and 
excellent food and can be made into appetizing dishes for 
breakfast or lunch. 

(e) That oatmeal, macaroni, rice, and gluten flour have 
more growing material than potatoes or white flour. 

(/) That in using nuts, cheese, and beans the question of 
individual digestion must dictate the choice. 

In comparing the prices of the different foods, we should 
consider the amount of nourishment they contain as well as 
the price per pound. 



THE HOME HYGIENE OF CHILDREN 77 

Eating between meals should only be allowed where it is 
prompted by hunger and not by a desire for goodies= Only 
easily digested foods, as crackers and fruit, etc., should be 
given at such times. 

The nourishment should be fairly well distributed among 
the three meals, and not crowded mainly into the dinner. 

The weekly dietary should contain considerable variety, 
but the single meal not too great a mixture. 

Study the effects of combinations before discarding any 
food from the diet list. 

Never crowd nourishment nor risk indigestible food on 
occasions of excitement or fatigue. 

After indulgence in an unusually heavy or taxing meal 
see that the next one is unusually simple. 

When protein is added to the dinner for the sake of the 
children, the "grown-ups" may eat less of the meat. The 
necessity for careful mastication is a lesson that children can- 
not be taught too early. 

If, in spite of reasonable food habits, a child remains 
badly nourished, one must seek for deeper causes, in which 
the aid of a skilful physician will ordinarily be required. 
Perhaps the child has a local form of tuberculosis or is a 
sufferer , from malaria (in malarious countries); perhaps he is 
suffering from fatigue, which again may be caused by a 
great variety of conditions; or he may have adenoids, or 
diseased tonsils, or require circumcision. But in most cases 
careful attention to the bowels, to fresh air, good food, plenty 
of sleep, to firm discipline and wholesome and interesting play 
exercises, will solve the problem of the mahiourished school- 
child. 

Ventilation. — It would seem that no particular attention 
need be called to-day to the necessity for good ventilation 
in the home. The following figures, however, taken from the 
writer's personal data, will demonstrate that ventilation has 
as yet not received the attention it deserves in a great many 
families. 



78 EDUCATIONAL HYGIENE 

Of 68 1 children questioned in fifteen Minnesota cities, 385, 
or a little over 50 per cent, sleep in unventilated bedrooms. 
In Chisholm, Minn., of 425 children questioned, 237, or 
about 50 per cent, confessed to no bedroom ventilation. 
In another Minnesota city, of 272 children, 176, or about 
64 per cent, have no ventilation in the bedroom. 

These figures correspond closely with those obtained by 
the writer in other places. Even in Berkeley, California, 
where the climate is mild, it appears that about 25 per cent 
of school-children are denied fresh air at night. 

Poor ventilation affects the health not so much because 
of chemical changes in the air breathed in a close room, but 
mainly because in such rooms there is abundant opportunity 
for infection with various contagious diseases. Yet any one 
who has enjoyed the privilege of sleeping out of doors, or in 
an open-air room, knows the exhilaration which is sure to 
follow, and such people invariably notice the ill effects of a 
sudden change to indoor sleeping. Poor ventilation, in some 
way not altogether understood, reduces general vitality, as 
well as resistance to specific infections, but it may be said 
that these results are due largely to a high degree of hiunid- 
ity and lack of movement of air currents. 

It ought not to be necessary to affirm that fresh air, day 
or night, injures no one, not even the most delicate; that, on 
the other hand, it is one of the chief remedies for the cure of 
tuberculosis, pneumonia, neurasthenia, as well as some less 
definite general disorders. 

Headache. — That headache is a common disorder of chil- 
dren is clearly shown by figures taken from the writer's data. 

In Owatonna, Minn., 24 per cent of 570 children were 
found to be sufferers from chronic headache, that is, headache 
at least as often as two or three times every week, and in 
many cases every day. In thirteen other Minnesota cities 
1,070 children were questioned and of these 23.9 per cent 
were discovered to have frequent headache. 

Other figures give similar results, and it is therefore safe 



THE HOME HYGIENE OP CHILDREN 79 

to say that about one-quarter of the children of school age 
are afiflicted with much headache. 

The reasons for this rather serious handicap are not en- 
tirely clear, but in the main it may be said that it is usually 
due to one or more of the following conditions: 

(i) Constipation. 

(2) Eye-strain. 

(3) Poor ventilation of home or school. 

(4) Fatigue. 

(5) Auto-intoxication or intestinal indigestion. 

The main causes once being understood, it is usually not a 
difficult matter to correct and control them. 

Constipation calls for careful inquiry into proper diets, 
and adequate and abundant use of drinking-water. 

Eye-strain calls for a visit to the oculist and the use of 
properly fitted glasses. Do not patronize opticians for vision 
examinations. 

Bad air should not be tolerated in any home or school in 
any climate under any conditions. 

Fatigue needs careful investigation. The child may be 
overstrained nervously either at home or at school, and in 
either case the advice of an intelligent physician will be needed. 

Auto-intoxication is ordinarily due to starch-indigestion 
or other diet errors, or to chronic constipation. 

In respect to constipation, one should understand that 
the use of cathartics except as temporary expedients is to be 
strictly condemned. Most cases of constipation may be rather 
easily corrected by the use of a mixed diet including some 
coarse foods and plenty of water, combined with vigorous 
exercise. Massage and other special exercises of the abdominal 
muscles are often useful. 

Disorders of the Eyes, Ears, Nose, and Throat. — These 
disorders are very serious and important, but cannot be given 
extended discussion. Parents may well consult Terman's 
"The Hygiene of the School Child" or other good books on 
these vital topics. 



8o EDUCATIONAL HYGIENE 

Attention may, however, be called to the fact that fre- 
quent sore throat is an almost infallible sign of diseased 
tonsils; that rheumatism, tonsilitis, and St. Vitus's dance are 
closely associated; that adenoids cause mouth breathing, 
crooked teeth, nasal voice, earache and discharge, and even 
running ear, and deafness; that pecuHar postures of the head, 
red eyes, crossed eyes, painful eyes, and granular lids are often 
caused by defects of vision. Blurring of the print and double 
vision are sure indications of serious eye trouble.* 

The parent should also be reminded that defects of vision 
require the best skill of a reliable oculist and that the "opti- 
cians" are usually very unreliable in their eye work. 

The Teeth. — ^At least 65 per cent of children between five 
and twelve years of age have seriously defective teeth. Often 
the proportion is much greater. 

Defects of the teeth are not only offensive to the aesthetic 
sense, ■ but they produce many bad results to the general 
health both directly and indirectly. It is only necessary to 
state here that the first teeth require just as careful attention 
as the second, and, what is more important but not as well 
understood, that decay of the teeth, both first and second, is 
largely preventable by proper hygienic attention. Preventive 
dentistry is far more important and much less expensive than 
corrective dentistry. Deformities of teeth and jaws should be 
corrected early and not allowed to go uncorrected until the 
bones of the face are completely developed. This is a point 
which even some dentists and physicians seem not fully to 
understand. 

Conclusion. — A very great deal of attention is paid by 
the national and local governments and by farmers every- 
where to the proper upbringing of hogs, cattle, horses, sheep, 
and the like. MilHons of dollars are annually spent to pro- 
mote the health and proper nurture ®f these domestic brutes, 

» Teachers will find much help in Cornell's "Health and Medical Inspection 
of School Children," and in the author's "Health Index of Children," and 
Hoag and Terman's "Health Work in the Schools." 



I 



THE HOME HYGIENE OF CHILDREN 8 1 

and a technical science has been developed. Many farmers 
rear their live stock better than they do their own boys and 
girls. City parents are about as ignorant. We bespeak for 
the children the earnest attention and studious care of their 
parents. The hygiene of children may prove as interesting 
to learn as bridge whist or the prevention of hog cholera. 



CHAPTER V 

PUBLIC CO-OPERATION FOR SCHOOL-HEALTH 

AGENCIES 

The Necessity for Public Co-operation. — The reasons for 
asking public aid in the development of school hygiene arise 
partly from the conditions under which knowledge is dif- 
fused and partly from the nature of our democratic institu- 
tions. The discoveries of new appHcations of scientific prin- 
ciples are first made by individuals, and they spread to other 
individuals and groups only through the slow process of 
publication in periodical, pamphlet, or book. The use of 
vacuum-producing machinery, for example, for the removal 
of dirt from floors, is a process which was known to a few 
some time before it reached school ofiicials generally, and 
doubtless there are some who even yet are not well informed 
about it. The latest word in ventilation has reached probably 
only the immediate circles which surround the scientists who 
are working upon this problem. Since municipal depart- 
ments do not ordinarily provide facilities for gaining infor- 
mation, school officials are obHged to depend upon outside 
agencies for much of the data regarding the most recent 
methods if they would keep abreast of the ever-advancing 
waves of health knowledge. But this is only a minor occasion 
for seeking outside co-operation. 

The Inertia of Democratic Institutions. — Since among 
democratic institutions modification of function, theoretic- 
ally and practically, generally results from the impact of 
pubKc sentiment, the adoption of new methods must proceed 
much more slowly in a democracy than it does in a mon- 
archical form of government. But if the knowledge of new 

82 



4 



PUBLIC CO-OPERATION 83 

hygiene methods spreads slowly, a process even more dila- 
tory is the assumption of such methods as regular functions 
by our public institutions. An illustration is found in the 
case of school medical inspection. In this country its in- 
ception took place in Boston in 1894, and in 191 1, according 
to statistics^ compiled by the Russell Sage Foundation, only 
443 cities, or 43 per cent of the 1,038 cities reporting, had 
adopted medical school inspection. And of the 443 only 102 
had put in school nurses, and only 69 were employing school 
dentists. 

Again, boards of education, like other governmental bodies, 
are not only slow in initiating novel methods but they 
are also slow in extending them to all parts of the system. 
For example, many cities have estabhshed some open-air 
schools but few if any have as yet made adequate provision 
for all the anemic or pre-tubercular children now attending 
their classes. The explanation is to be found in the fact that 
boards of education cannot move, even when the legal author- 
ity is clear, without adequate funds, and the appropriation 
of funds is ultimately dependent upon pubHc approval. 
Since school officials are Hmited in their power to arouse pubHc 
sentiment in favor of new machinery, they are obliged to de- 
pend upon assistance from outside agencies. These can co- 
operate both in piecing out the partially adopted activity 
and in developing the pubHc support necessary to place it 
upon an entirely adequate basis. 

The Service of Criticism. — It sometimes happens that 
medical inspection which has been long maintained becomes 
inefficient. The school authorities may suspect the existence 
of unsatisfactory conditions and yet not have, or be in the 
position to obtain, the evidence necessary for their correction. 
Here again is afforded an opportunity for some friendly ex- 
ternal organization to carry on an investigation which, be- 
cause of its foreign auspices, will be considered more impartial 
than an investigation carried on by the board of education 
» "Medical Inspection of Schools," Gulick and Ayres, p. 15. 



84 EDUCATIONAL HYGIENE 

itself. Again, in the administration of hygiene activities 
overlapping sometimes occurs, and thus a condition is brought 
about which can be remedied only by a third party. Only 
under rare circumstances can one department co-ordinate its 
work with that of another without the intervention of all 
unbiassed umpire. 

Public Co-operation Increasing. — In the early days when 
leadership in school matters was more largely left in the hands 
of prominent citizens, often men of learning and standing as 
educators, the co-operation of outside agencies was not only 
not sought but even considered meddlesome. With the in- 
creasing public concern regarding child welfare, however, 
and with the development of larger initiative on the part of 
the school officials themselves, a different order has come 
about. To-day the school reports from the more enterprising 
cities are replete with acknowledgments of indebtedness to 
outside agencies for various kinds of valuable assistance. ^ 

The Differentiation of the Public. — For the purposes of 
this chapter the pubHc is considered to include all those per- 
sons and private bodies which are not under the control of 
the school authorities. This public, to which school officials 
may look for co-operation, is divided into individuals and 
voluntary organizations, and it is from the latter bodies 
that the most efficient help ordinarily comes. The reason 
for this latter fact is that voluntary organizations represent 
and give expression to particular interests. In the act of 
formation itself a selection is automatically made of those 
individuals who are either specially interested or proficient 
in the activity for the performance of which the group was 
originally called together. The voluntary society is, indeed, a 
tentative variation in the structure of the social organism 
whereby certain of its elements combine to perform a new 
function. If this special activity prove to have a preserva- 
tive value society nourishes it, provides it with bone and 
sinew, and finally articulates it with its other fixed institu- 
tions. 

» See Cabot's "Volunteer Help to the Schools." 



PUBLIC CO-OPERATION 85 

The Varieties of Private Organizations. — When grouped 
according to function the various voluntary and quasi-public 
associations to which school officials may resort for health 
assistance fall into seven fairly distinct classes, although there 
is considerable overlapping, many bodies carrying on activ- 
ities which fall into two or three different categories. 

(i) The first group is the one upon whose achievements 
all the others are dependent. It is composed of the organiza- 
tions which develop new knowledge. Their workers are 
scientists who are working in the van of advancing civiKza- 
tion. They include such bodies as the Rockefeller Institute, 
the Carnegie Foundation, United States Bureau of Health 
Service, faculties of medical colleges, and other associations 
which are composed of physicians, sanitary engineers, and 
research specialists in chemistry, physics, and ^Jie biological 
sciences. 

(2) The next group is composed of the bodies whose ex- 
perts develop through statistical methods the facts regarding 
the existence of disease, the data of which show the need of 
improved health methods. Such a body is the Committee 
of One Hundred on National Vitality of the American Asso- 
ciation for the Advancement of Science. In this field also the 
various insurance companies are, through their actuarial de- 
partments, doing most important work. 

(3) In the third class fall the organizations which inves- 
tigate the various methods by which scientific principles of 
hygiene are put into effect. They examine the results ob- 
tained under different forms of public administration and 
make their researches available in pubHshed reports. Among 
the organizations^ performing this function may be men- 
tioned the National Association for the Study and Preven- 
tion of Tuberculosis, the Russell Sage Foundation, the Life 
Extension Institute, the National Association for the Study 
and Prevention of Infant Mortality, and the United States 
Public Health Service. 

* For a more comprehensive list of these various organizations see " Educa- 
tional Problems," by G. Stanley Hall, Chapters XI and XII. 



86 EDUCATIONAL HYGIENE 

(4) Associations for propaganda, which stimulate and 
direct campaigns for the adoption of hygiene activities, con- 
stitute the next class. Some of these have already been named 
in the preceding category, since they perform both of these 
functions. A notable instance is to be found in the national 
and local bodies which are pushing the fight against tubercu- 
losis. Other examples are the Playground and Recreation 
Association of America, the Woman's Christian Temperance 
Union, the General Federation of Women's Clubs, National 
Conference of Charities and Correction, and similar organi- 
zations.^ 

(5) The local charitable and philanthropic organizations, 
medical and dental societies, women's clubs, chambers of 
commerce, and social settlements indicate the character of 
the next class. These bodies assist by promoting the estab- 
lishment of hygiene activities in local institutions and by ad- 
ministrative co-operation in incipient and inadequate sys- 
tems.. They are often the local groups through which the 
national bodies mentioned in the preceding category perform 
their work. 

(6) Bodies such as the Public Education Association or the 
Bureau of Municipal Research which do local research work 
and assist not only in the strengthening of municipal depart- 
ments but also endeavor to help in the co-ordination of their 
activities, comprise this group. 

(7) The last group is composed of mothers' clubs, parent- 
teacher societies, ward improvement and taxpayers* associa- 
tions, and other bodies of citizens which maintain a receptive 
attitude toward health information. These are the groups 
through which school authorities and other interested bodies 
can accomplish a diffusion of health facts so as to develop a 
supporting environment for the school hygiene activities. 

Information about Hygiene Methods. — The task of keep- 
ing in touch with the latest school hygiene data is greatly 

1 See Report of the Commissioner of Education, 1912, vol. I, "Typical 
Health Teaching Agencies of the United States," by F. B. Dresslar, pp. 299-358. 



PUBLIC CO-OPERATION 87 

facilitated for school officials nowadays, by the vast numbers 
of bibliographies and the pamphlets of the propagandistic 
organizations, and the various government bulletins which 
the Hbraries are compiling and collecting. The Federal 
Bureaus of Labor, Education, and Children, and the United 
States Public Health Service, are constantly sending out 
pamphlets bearing upon health topics. But the school super- 
intendent has not only to keep himself informed; for the 
successful carrying out of his plans it is necessary that the 
members of the board of education and the principals and 
teachers constituting his staff should likewise be well informed. 
For this education in health methods within the school sys- 
tem much help can be obtained from various volunteer or- 
ganizations. Lecturers may be obtained from local medical 
and dental societies, and the staffs of the various propagan- 
distic organizations working in the health field. Many of these 
societies have lantern-sHdes or motion-pictures which can be 
borrowed for public meetings. The platform discussions may 
also be supplemented by carefully chosen and tactfully dis- 
tributed pamphlets. 

Information should be sought, however, not only concern- 
ing the most improved health methods in other cities, but 
facts should also be obtained about the sanitary conditions 
in the superintendent's own system, as without this informa- 
tion thoroughly efficient administration cannot be maintained. 
These data the superintendent can to a certain degree obtain 
for himself; it all depends upon the research facihties at his 
command. Often he is obliged to call upon some outside 
agency either for assistance in carrying on an investigation 
or to take entire charge of one. Since in the latter case, 
through the mere bringing of a voluntary organization into 
intimate contact with the school system a certain proportion 
of the outside public is caused to become vitally concerned 
about school conditions, this topic affords an appropriate 
transition to the next subject that requires our consideration. 

Creating Public Sentiment. — The importance of seeking 



8S EDUCATIONAL HYGIENE 

aid from outside organizations having a large and influential 
membership in the task of making sanitary surveys is immedi- 
ately seen when it is realized that the facts as to bad conditions 
are of little value unless they can be followed up by adminis- 
trative changes which will remedy and prevent the recurrence 
of the objectionable conditions. When the members of the 
woman's club, for example, go about from school to school 
filling out a sanitation or other questionnaire, they actually 
enter the environment in which the children of the commu- 
nity spend a large portion of their days. If this environment 
is not healthful they are immediately filled with an ardent 
desire to change it, and thus a vast amount of public senti- 
ment is automatically created and set to spreading. 

Miss Elsa Denison's ''Helping School Children" — a most 
suggestive treatment of the whole subject of public co-opera- 
tion — describes in Chapters VII and VIII many kinds of 
assistance which women's organizations are rendering school 
officials. Mention is made of the investigation of the Boston 
public schools by a branch of the Association of Collegiate 
Alumnse, which resulted in the formation of a new school 
code; also of the survey performed by the Arundel! Club in 
Baltimore, and by the Public Education Association in Provi- 
dence. The extensive questionnaire used by the New Jersey 
Federation of Women's Clubs in its State- wide study of school 
conditions is also set forth. 

Getting the Evidence. — In meeting the necessity for 
concrete, objective evidence, when seeking to bring about 
extensions or improvements in hygiene activities, school 
officials have received much assistance from the local medical 
and dental associations. In Philadelphia Doctor Samuel W. 
Newmayer developed some data showing the need of the co- 
operation of school nurses in medical school inspection. His 
figures^ show that in the four schools where the inspector 

1 Reported in the Proceedings of the Fifth Annual Congress of the American 
School Hygiene Association under the title, "Evidence that the School Nurse 
Pays." These results are also printed in "Medical Inspection of Schools," 
Gulick and Ayres, pp. 66-67, revised edition. 



I 



PUBLIC CO-OPERATION 89 

was assisted by a nurse 89 per cent of the recommendations 
were acted upon, whereas in an equal number of schools where 
the medical inspector was unassisted only 24 per cent of the 
recommendations were followed by action. 

In Philadelphia also a very effective argument for dustless 
cleaning in pubHc schools was developed through a tabulation 
by months of contagious diseases among children. The ev- 
idence was graphically shown by means of various columns 
proportioned to the respective monthly figures. The very 
low columns during the summer months, the open-window 
period, and the overtowering columns of the winter and 
early spring months when the windows are closed and the 
dust-carried germs have undisturbed sway, constitute an illu- 
minating lesson. There are few cities where it would be 
difhcult to find some organization or individual who would 
assist a superintendent by delving into the local t'ital statistics 
and compiling a similar table. 

During a mouth hygiene campaign in Cleveland directed 
by national and local dental associations, over 20,000 pupils 
were examined and in 97 per cent more or less faulty mouths 
were found. Facts such as these have a convincing power 
and a publicity value that is never possessed by any single 
man's convictions or opinions, however well stated or whatever 
his reputation. 

A committee of the Public Education Association of New 
York City recently employed a specialist to make mental 
examinations in connection with the work of the ungraded 
classes in the public schools. On the basis of these examina- 
tions a reorganization of this department was effected. 
Many other instances of this form of co-operation could be 
adduced. 

Publicity for the Facts. — ^After developing the facts needed 
to reinforce a request for the introduction or extension of 
medical inspection, or of any other hygiene activity, a great 
deal of thought can profitably be given to the best way of 
causing these facts to reach the pubhc. A very common 



go EDUCATIONAL HYGIENE 

method is by means of the superintendent's annual report. 
A suggestive example is found in the Northampton, Massa- 
chusetts, school report for 191 2. The superintendent desired 
a school nurse, and by way of bolstering his argument he 
mentions some actual cases which came to his attention 
during a single visit to one school: 

An intelligent parent who does not agree with the head of the 
Boston dispensary that two- thirds of the so-called physical defects 
of children are caused directly or indirectly by decayed teeth allows 
a child to be poisoned by decaying teeth on the theory that the first 
teeth being temporary do not need any attention; a hard-working 
mother who does not know what to do to prevent scabies from spread- 
ing in her family allows her children to run wild and blames the schools 
for excluding them; indulgent parents allow a nine-year-old boy to 
drink six cups of coffee a day, then wonder why he fails to do his work 
at school and is so nervous that at times he has no self-control; a 
mother should have her attention called to a vicious habit which a 
wide-awake teacher has discovered in her eight-year-old boy; a non- 
English-speaking mother needs help in freeing her children's heads 
from parasites, as she cannot read the directions sent her from the 
school. 

But, since in school reports health matters must necessa- 
rily be mixed with many other topics, an even better method 
is available when a volunteer agency makes the investiga- 
tion, and that is to let it pubHsh its own report. Thus the 
evidence goes before the pubKc in a conspicuous manner and 
under supposedly impartial auspices. In the inquiries un- 
dertaken by the Public Education Association, Bureau of 
Municipal Research, or the Woman's Club it is customary 
to pubHsh the results in striking, individual reports. 

Exhibiting the Facts. — One of the most effective instru- 
ments for developing public-health sentiment employed in 
recent years is the child-welfare exhibit, and there are many 
instances where such exhibits have been arranged by women's 
clubs, local bureaus of municipal research, and other associa- 
tions. Detailed information upon exhibit methods can be 
obtained from the Department of Surveys and Exhibits of the 



PUBLIC CO-OPERATION 9 1 

Russell Sage Foundation, the National Child Welfare Exhibit 
Committee, and the New York Bureau of Municipal Re- 
search. 

Public Meetings. — In campaigns for open-air schools the 
services of publicity experts can often be secured from the 
local society for the prevention of tuberculosis. Through long 
experience with the problem of awakening the public to active 
measures against the white plague, the people connected with 
this organization have worked out very successful methods. 
Campaigns of considerable effectiveness can also be carried 
on with the aid of the local woman's club, chamber of com- 
merce, medical associations, and parent-teacher organiza- 
tions.^ An instance of the boost to school hygiene that is 
accomplished through the occasional meeting is found in the 
informal conference and reception held under the auspices 
of the Social Science Department of the Peoria (Illinois) 
Women's Club in honor of Miss Crandall, of New York, who 
spoke on "New Aspects of Visiting Nurse Work," emphasiz- 
ing the importance of the pubHc-health nurse. To this con- 
ference the department invited the members of the Visiting 
Nurses' Association, Registered Nurses' Association, the 
Mothers' Club, and the Teacher and Kindergarten Clubs. 
Very often through the social-service departments of the 
local rehgious denominations, sermons upon the desired topic 
can be secured in many of the churches. 

The Newspapers. — One of the chief values of the public 
meeting as an instrument for developing public opinion is 
the pubHcity which is thereby gained through the news- 
papers. To meetings at which prominent persons are brought 
together, both on the platform and in the audience, columns 
of space will be devoted, which are more valuable than paid 
advertisements. Likewise, through the judicious appoint- 
ment of important persons on committees and the reports 
of meetings of committees, much helpful publicity can be 

1 See "Wider Use of the School Plant," by Perry, Chapter XXI, "Meetings 
in School Houses." See also Chapter VII. 



92 EDUCATIONAL HYGIENE 

gained through newspaper accounts. The amount of space 
devoted to meetings can generally be augmented by a careful 
preparation for the reporters' needs. If copies of the speaker's 
address and lists of the committee memberships, and other 
informative documents, are prepared in advance for the news- 
paper men, their reports are usually not only longer but also 
much more accurate. 

As indicative of the value which newspaper editors at- 
tach to school items, it may be mentioned that in 191 1 the 
Bureau of Municipal Research^ clipped from twenty news- 
papers over a thousand news "stories" and editorials on 
school matters. Many superintendents are now taking ad- 
vantage of the opportunities afforded by the press in the con- 
scious development of a public sentiment favorable to their 
special projects. In accordance with a well-thought-out plan 
they are systematically selecting happenings in the school 
system in which the pubHc has a legitimate interest and are 
turning these items over to the reporters. In some cities, when 
the annual school report is ready the superintendent hands 
it out to the newspaper men first and helps them to find its 
most significant portions. If he has adopted a new school 
policy of broad import, he seeks a personal interview with the 
editor and endeavors to get the matter put accurately and in- 
telligently before the public. If he has completed an investi- 
gation which has revealed some significant and important 
facts, he turns his material over to some special writer. If a 
voluntary organization has rendered an important service, he 
sees that a definite account of it reaches the news columns. 
By thus facilitating the acquisition of school news on the 
part of the press he secures not only wide publicity for school 
matters but also a favorable attitude toward his work on the 
part of the most influential organ of public opinion. 

The Demonstration. — ^A method of developing influential 
support which seldom fails is that of the demonstration. 

1 " Outside Co-operation with the Public Schools of Greater New York," by 
the Bureau of Municipal Research, p. 12. 



PUBLIC CO-OPERATION 93 

Medical inspection in the schools of New York City was 
started in 1897, but during the first five years there was no 
school nurse. In 1902 nearly 18,000 children were excluded 
from the schools, and the classes were in some cases so de- 
pleted that it was difficult to carry on school work. To meet 
the serious situation thus created, the Henry Street Nurses^ 
Settlement offered the services of a school nurse for one month. 
At the end of that time the results of her work were so ob- 
viously beneficial that support was immediately gained from 
educational authorities, the board of health, and the pubHc 
for the employment of school nurses.^ 

Similarly, in Philadelphia the Visiting Nurses' Society 
loaned a trained nurse to the city to show the value of this 
adjunct to medical inspection. Like demonstrations have 
also been carried on in favor of medical inspection through 
the co-operation of the local associations of physicians and 
dentists. 

Securing Codes and Regulations. — The proper result to 
follow revelations concerning insanitary conditions is the 
passage of measures or the establishment of activities whereby, 
it is hoped, the repetition of the evils discovered will be avoided 
in the future. Thus, through the investigation by the Col- 
legiate Alumnae, already referred to, Boston received a new 
school code. But the results of an investigation, a survey, 
an exhibit, or a campaign of publicity will not automatically 
translate themselves into new regulations. Unless some one 
follows them up, the public sentiment they arouse will die 
away without concrete results. There are plenty of publi- 
cations which describe the best forms of codes to meet the 
various exigencies in school hygiene, but they do not often 
give information as to the best way of manipulating the 
local social forces through the marshalling and concentration 
of which the passage of the code will be secured. Every 
resolution, ordinance, code, or statute has to receive the ap- 
proval of a certain majority, no two members of which have 

^This first municipal school nurse has written a chapter for this volume. — Ed. 



94 EDUCATIONAL HYGIENE 

the same view-point, S)nnpathies, or information, but each of 
whom can be moved by some influence or other, and not a 
sordid one at that. The problem is to find the effective in- 
fluence and to bring it to bear at the right time upon the 
right person. With one individual it will be more evidence 
of the actual physical need, and in the case of another evidence 
of the public demand, or the suasion of an influential friend. 
The skilful superintendent will make a careful canvass of 
the opinions of the members from whom he is seeking legis- 
lation and tabulate the obstacles which stand in the way. 
He will then deploy the forces at his command with a view to 
overcoming them, in the same careful way that the general 
plans a siege of a city. Oftentimes there is to be found in 
the local civic or philanthropic circles some live secretary 
who is also something of a poHtical tactician, whose services 
can be secured for assistance in this work. The school board 
of MinneapoHs called for a commission of local medical men 
to advise with the board on all questions of school hygiene. 
This commission prepared a comprehensive report covering 
all phases of the subject, and has manifested a willingness to 
remain as a permanent advisory body. There are few local- 
ities in which similar co-operation cannot be obtained from 
public-spirited physicians, dentists, and oculists. 

Co-operation in Administration. — ^The British Board of 
Education urges local school authorities to secure the utmost 
possible degree of co-operation from hospitals and clinics in 
their physical ministrations to pupils; and the same practise 
is being followed in many places in the United States. When 
medical inspection is first inaugurated, it often occurs that 
sufficient funds are not provided to enable the examination 
of all pupils with adequate frequency or thoroughness, so 
that outside assistance is still greatly needed. Frequently a 
school nurse is not provided, or funds will not allow the pur- 
chase of the necessary dispensary articles. An open-window 
schoolroom may be provided but no food or the kind of 
garments required for fresh-air work during the cold months. 



PUBLIC CO-OPERATION 95 

These shortcomings create an opportunity for outside co- 
operation which is being very generally utiHzed throughout 
the country. 

From Medical Associations. — Prominent in this kind of 
co-operation are the county or local medical associations and 
the public-health association. In Kenosha, Wisconsin, eight 
physicians connected with the local medical association gave 
their services for three years in the performance of an an- 
nual medical inspection of school-children. In Rochester, 
New York, the Public Health Association furnishes food and 
equipment for the open-air school. 

Physicians. — Sometimes individual physicians take turns 
in donating a month's services to the examination of school- 
children, or nose and throat speciaKsts will co-operate in the 
running of a cHnic for nose and throat operations. In Houston, 
Texas, the Association of Optics and Aurists co-operated with 
the local school board in the work of medical inspection. Many 
instances of this kind are revealed in the current school re- 
ports. 

Dentists. — The Harvard Dental School gives treatment 
to pupils at reduced rates, while the dental school connected 
with Tufts College also receives pupils who are sent to it by 
school nurses. Dental clinics for the benefit of school-children 
are maintained also in the Louisville (Kentucky) College of 
Dentistry, the Homeopathic Dispensary at Orange, New 
Jersey, and the Memorial Hospital at Pawtucket, Rhode 
Island. Doubtless there are many other institutions of this 
sort performing a similar service for school-children. 

Even more common are the instances of co-operation 
afforded by local dental societies. School reports make fre- 
quent reference to the inspection, clinical services, and pubHc 
lectures which are given by members of these organizations. 
Sometimes the services are free and at other times partly 
paid. In some instances only the inspection is made, while 
in others it is followed up with a regular cKnical service. 
The Cincinnati school report for 1912 has a very suggestive 



96 EDUCATIONAL HYGIENE 

account of the work performed by the Cincinnati Dental 
Society. Its activities include inspection, maintenance of 
free clinic, lectures given school-children, parents' clubs and 
social settlements, and alHed organizations. Recently, in 
connection with the work of the clinic, experimentation has 
been carried on with a view to showing the different physical 
and mental results obtained from a class whose members- 
mouths were kept in hygienic condition and from a class not 
receiving systematic attention. Again, individual dentists 
help school authorities by inspection, free treatment to needy 
pupils, or even monetary contributions to help carry on the 
work of the school clinic. 

Hospitals. — ^The assistance given by hospitals varies 
more or less in accordance with the facilities of the institu- 
tion. That afforded by the Boston hospitals is especially 
notable. The Massachusetts General Hospital gives medical 
and surgical attention to poor children for a ten-cent fee. 
The same service is also offered by the out-patient depart- 
ment of the Massachusetts Homeopathic Hospital, while 
the Children's Hospital not only furnishes medical treatment 
for pupils but arranges a course of instruction for school 
nurses. At the Massachusetts Charitable Eye and Ear In- 
firmary treatment may be received for a nominal fee, and in 
addition eye-glasses are supplied and investigations made of 
the home conditions of afflicted children. The New England 
Hospital for Women and Children examines children before 
they are sent out on summer vacations. It also maintains 
a dispensary service open to pupils. The Boston and the 
Maverick dispensaries treat children who are sent to them by 
the school nurses. In the psychopathic department of the 
Massachusetts State Hospital mental examinations of school- 
children are carried on. The institutions of many other 
cities are performing similar services for school-children. 

Charitable Societies. — From the provident associations, 
children's aid societies, and other charitable organizations in 
the same class a vast amount of co-operation is being received 



PUBLIC CO-OPERATION 97 

by the schools in the physical care of children. Eye-glasses 
and clothing are provided, attention given to special cases 
reported by the school nurses, and the home conditions in- 
spected and improved. Some organizations give attention 
to the work of facilitating country or seashore vacations for 
needy children. 

The needs peculiar to crippled children are being at- 
tended to by organizations established for their particular 
benefit. Some of these bodies afford transportation, free 
meals, or medical and surgical aid to those in attendance 
at the public schools. Others provide educational facihties 
for those whose condition debars them from the public schools, 
and in some instances trained nurses are sent to visit the 
homes of these unfortunates. Likewise the deaf and the blind 
are the recipients of the special attentions wkich they require 
from another class of institution. 

Nursing Associations. — Another source of most valuable 
co-operation is found in the various nurses' associations. 
The Instructive Nurses' Association of Boston provides home 
attention for the particular cases referred to it by school 
nurses, while the District Nurses' Association of Scran ton, 
Pennsylvania, supervises the instruction of school nurses; 
and many other associations are loaning nurses to the school 
department or helping it to demonstrate the need of this 
most important adjunct to medical school inspection. The 
co-operation given to the schools in this field is as miscel- 
laneous as it is important. 

Settlements. — Reference has already been made to the 
nurse who was loaned to the New York schools by the Henry 
Street Nurses' Settlement. This institution now maintains, 
under the board of education, a class for mental defectives, 
and also facilitates country vacations and provides milk for 
undernourished children. Furnishing school nurses, giving 
health talks to parents, maintaining open-air schools, special 
clinics for children with uncommon diseases, schools for sick 
and shut-in children, agitations for more sanitary buildings, 



98 EDUCATIONAL HYGIENE 

larger playgrounds and more apparatus — these are only 
samples of the kinds of assistance which settlements through- 
out the country are rendering school systems. 

Tuberculosis Societies. — The national and local associa- 
tions for the prevention of tuberculosis, as might be expected, 
are giving valuable aid to the school authorities in the estab- 
lishment of open-air schools. The pioneer work of the Provi- 
dence (Rhode Island) school committee in this field was 
stimulated by a suggestion of the local League for the Sup- 
pression of Tuberculosis, and the physicians who composed 
the committee of this organization assisted in the selection 
of pupils for the school. In some instances the local tuber- 
culosis association erects the building and becomes a chief 
supporter of the work; in others it provides the coats, suits, 
and other portions of the equipment or the meals. Some- 
times the society provides lectures on hygiene in the various 
schools. In addition to this kind of service the Pawtucket 
(Rhode Island) Society for the Prevention of Tuberculosis 
presented forty dollars' worth of tooth-brushes and samples 
of tooth-paste to the school nursing department. The Wis- 
consin Anti-Tuberculosis Association offered a complete open- 
air school equipment to the city of that State making the 
highest per-capita sale of Christmas seals. This equipment 
was won by Kenosha, as were also the services of a visiting 
nurse for one month, furnished by the association. 

Women's Clubs. — ^A vast amount of service is being 
given to the promotion of child welfare by the women's clubs. 
Active from the outset in the playground propaganda, they 
are now devoting their efforts to the estabhshment of school 
lunches in high and elementary schools, arranging child-wel- 
fare exhibits, agitating the estabhshment of open-air schools, 
supplementing the equipment of school nurses, and urging 
the importance of the best methods of medical and sanitary 
school inspection. 

Parent-Teacher Associations. — Still closer to the school 
are the parent-teacher organizations with their varied activ- 



PUBLIC CO-OPERATION 99 

ities and services. Some are maintaining school-lunch de- 
partments, others purchasing playground apparatus, or em- 
ploying home and school visitors, and installing first-aid 
outfits. The Fathers' and Mothers' Club of Boston main- 
tains a farmhouse for anemic children. These organizations, 
so dependent upon the school for their existence, generally 
consider opportunities for co-operation in the light of great 
privileges. 

Oftentimes the local university is in a position to extend 
valuable co-operation. The Department of Psychology of 
the University of Cincinnati gave mental examinations to 
exceptional children, and the University of Pittsburgh is 
maintaining a similar service. The local railway companies 
sometimes assist teachers in their instructions concerning the 
avoidance of accidents by furnishing blotters teaching the 
results of carelessness in boarding and departing from street- 
cars. A Safety League in Kenosha, Wisconsin, arranged 
lectures in the public schools upon the various methods of 
promoting safety. 

Individual Philanthropists. — In the conduct of the Chicago 
schools for anemic children the board of education supplies 
the rooms and teachers, while the Elizabeth McCormick Fund 
provides the extra pay of the physicians and nurses and meets 
the expense attached to furnishing food and supplying extra 
clothing and equipment. 

The Forsyth Dental Infirmary of Boston, just being opened, 
will attempt to care for the mouth conditions of all the chil- 
dren of Greater Boston up to sixteen years of age. The in- 
stitution was founded by two brothers as a family memorial. 
The benefactors purchased the site, erected the building, 
which cost $250,000, and have endowed the holding corpora- 
tion with a maintenance fund of about $1,000,000. The 
institution has facilities for sixty-four chairs, and auxihary 
room for forty-four additional ones. It is expected that it 
will be possible to treat over seven hundred cases daily. 

The application of philanthropic funds to the field of 



lOO EDUCATIONAL HYGIENE 

school hygiene is, according to the signs of the times, likely 
to show still further extension. 

Assistance in Bringing about Co-ordination. — This sort of 
service is illustrated in the work of the PubHc Education As- 
sociation of the City of New York. It brought together 
representatives of the departments of Health, Charities, 
Education, and the Children's Court, as well as a number of 
private citizens, in a special committee devoted to the pro- 
motion of child welfare. The purpose of this body was to 
develop intelligent co-operation between these different de- 
partments, to define the problems of school hygiene, and to 
carry on intensive studies of some of the more difficult ones. 
A member of the association staff was assigned to the work of 
this committee. 

Encouraging Voluntary Assistance. — The Boston report 
for 1 91 3 devotes twenty pages of fine type to a concise state- 
ment of the one hundred and twelve organizations which are 
co-operating with the public schools of that city. Many of 
the current school reports are also stating the needs of the 
schools, which would afford opportunities for volunteer co- 
operation. Thus by inviting co-operation and giving accurate 
credit for the work that is done, the welfare of school-children 
is being more rapidly advanced than is possible through the 
unaided activities of present school systems. 

Educating the Home and the Public in Health Practises. 
— In order that the school's hygiene activities may fuid sup- 
port in the pupils' home and neighborhood environment, it is 
necessary that much miscellaneous health instruction be pro- 
vided for the community which is outside of the school- 
building. And in this work the volunteer associations also 
are unusually helpful. The Public Education Association of 
Philadelphia prepared and distributed through the school- 
children ten thousand cards of health instructions to parents. 
It also prepared and printed an equal number of highly 
effective pamphlets on the care of the baby for distribution 
among parents. The regular programmes of the various 



PUBLIC CO-OPEEATION lOI 

parent-teacher associations are full of illustrated lectures 
upon health topics. The women's clubs also arrange public 
meetings which are addressed by local physicians, dentists, 
and school inspectors. The Social Welfare Committee of 
the South Bend Chamber of Commerce arranges addresses 
upon health subjects before social-centre audiences in the 
pubHc schools; while the Commercial Club, of Louisville, 
Kentucky, in one year spent $6,000 on publicity work in 
behalf of the schools. Such associations as the Woman's 
Christian Temperance Union and the An ti- Cigarette League 
are always ready to avail themselves of opportunities to 
give public lectures upon their causes before schoolhouse 
audiences. The Boston Milk and Baby Association not only 
lectures upon its work before pupils but conducts "Httle 
mothers'" classes in the high schools. In Chicago the Visit- 
ing Nurses' Association arranged a series of lectures^ upon 
intestinal diseases in connection with the vacation schools, 
to which mothers were admitted as well as high and gram- 
mar school pupils. Many other examples of volunteer aid 
in the work of spreading the knowledge of health facts among 
the people in general might be brought forward if space 
permitted. 

The instances which have been set forth in this chapter 
illustrate but do not at all completely enumerate the various 
ways in which outside organizations are in many places al- 
ready co-operating, and in others stand ready to co-operate, 
with the educational authorities in promoting a steady ad- 
vance in school hygiene. So freely and bountifully, indeed, 
have the voluntary associations devoted means and personal 
service to human welfare that, in the light of their deeds, a 
new meaning now seems to shine forth — especially for all 
guardians of children — from that old scriptural saying, once 
rusted over with triteness: "Ask and ye shall receive." 

The following summarized suggestions by Wm. H. Allen, 
in his "Woman's Part in Government," are pertinent: 
*See "Wider Use of the School Plant," by Perry, p. 142. 



102 EDUCATIONAL HYGIENE 

The following first steps are suggested to local schools wishing 
to increase their power for civic education: 

1. Ask for a State law on medical examination of all children, 
teachers, janitors, buildings, and grounds in all school districts, public^ 
parochial, private, rural, and urban. 

2. Teach personal hygiene by relating it to community hygiene. 

3. Keep your communities continuously informed in regard to 
health needs indexed at school. 

4. Realize that every parent interested adds a teacher to your staff. 

5. Give your newspapers school stories and thus add 25 per cent 
to the efficiency of your teaching staff. 

6. Make private agencies supplement school work, instead of sup- 
plementing their work. 

7. Make your schools the centre of social-settlement work and up- 
lift work in your communities. 

8. Recognize that it is just as educational to interest the board of 
education and the voluntary visiting committee as to instruct a child. 

9. Provide for civic and health work by your school organizations. 

10. Take advantage of budget season to tell 100 per cent of school 
and health needs and to interest 100 per cent of your community in 
that story. 

11. Welcome complaints and questions as opportunities for civic 
education. 

12. Make more demands upon your State department of education 
and give it better support. 

13. Write your congressmen and senators to give the United 
States Bureau of Education enough work and enough money. 

14. Co-operate with the National Education Association's special 
committee on uniform and adequate records and reports. 



CHAPTER VI 
THE SOCIAL CENTRE AND EDUCATIONAL HYGIENE 

The Situation. — Sisyphus had to keep on rolling at the 
stone, even though he could not succeed. He had to keep on, 
or otherwise it would have rolled back and crushed him. 
And just so we must keep on spending our force in and through 
the pubhc-school system as it is to-day in pressing back the 
forces of disease and death in the programme of educational 
hygiene. We cannot stop using the means we have, for we, 
too, are laboring for our lives. % 

But, away back when first I heard of Sisyphus, I wondered 
why he did not hold the stone with one hand and shoulder 
and with the other hand or with his foot place a cobble under 
it, or somehow reach around and rig a block and tackle at 
the back of the stone by which his labor might be accom- 
plished. Had he been able to do that, he would not only 
have succeeded in his undertaking, but he would, so far, 
have spoiled and transformed Hades. The social-centre move- 
ment, the full use of the common-school system as the ma- 
chinery of adult and older-youth civic, industrial, recreational 
organization and co-operation, is the rigging of the block and 
tackle around behind the stone — the means by which the 
otherwise futile and discouraging enterprise of radically pro- 
moting public health through the agency of the public-school 
system shall become an achieving enterprise, whose process 
will go far toward transforming our inferno. 

Our experience in trying to make of the common-school 
system as it is — used one-third of the time, by only the one- 
third of us who are children, for the mere one- third of the 
educational process, which consists of children's instruction 

103 



I04 EDUCATIONAL HYGIENE 

— an effective and dynamic agency for the promotion of chil- 
dren's health, seems to necessitate this statement: 

The common-school system, as at present manned (or 
rather womaned), as at present housed (or rather barned), 
as at present stunted, fails, and is Hkely to keep on faihng, to 
be greatly, radically promotive of even the children's health. 

On the other hand, the experiments in social-centre de- 
velopment, even the little timid experiments that have been 
made thus far, justify this statement: 

When the characteristic community-building-and-yard 
equipment of America has ceased to be merely the children's 
school system, and has come to be really the public-school 
system, in use as well as in ownership, it will be the adequate 
machinery of public-health advance and so will make the 
health service of the children efhcient. 

Two Factors. — There are two necessary things to be done 
in order to make the public-school system an effective agency 
for health promotion. In the first place, the school must be 
radically improved in the character of its educational staff, 
in the character of its physical equipment, and in its curric- 
ulum. In the second place, the problem of sociological ad- 
justment, political, industrial, and recreational, must be dealt 
with. 

To-day the profession of the public-school man or woman 
is a third-rate profession. The salary standard is third-rate, 
and, in general, the professional calibre of the men and women 
employed in public-school service is one-third of what it 
should be. What is true of the personnel of the public- 
school service is in general true of the housing, grounding, 
and equipment of this characteristic American institution. 
And, judged by a standard of vital practical, economical, 
and constructive arrangement of physical and mental activ- 
ity of children in the public schools, the curriculum is not 
more than a third as good as it should be. 

What is the answer? " More money for the public schools," 
says President EHot. Yes, but how are we going to get it? 



SOCIAL CENTRE AND EDUCATIONAL HYGIENE 105 

There are other needs for the improvement of the public 
schools to the point where they will be efficient agencies in 
the promotion of health, other needs than money. How are 
these to be satisfied? 

The longest way round is often the shortest way home, 
and the problem of making the public school an efficient 
agency for health promotion is to be solved most directly by 
coming at it indirectly. 

Political Beginning. — The beginning of social-centre devel- 
opment is poKtical. Whether our objective be citizenship-train- 
ing improvement, moral-training improvement, industrial- 
training improvement, or health-promoting improvement in 
the efficiency of the public schools, the first step is the same. 
It is the shifting of the voting apparatus into the public 
schoolhouse. It is the use of the pubHc schoolhouse as the 
polling-place of its district. • 

The reason for this is not chiefly its economy, great as 
that is; it is because the establishment of the voting head- 
quarters in the school building makes of this building in actual 
practise a public place of assembly and organization. The 
^'pubHc" school as a juvenile instructional institution is not 
now, in practise, a common place of public assembHng even 
as the public is represented in the children. There are paro- 
chial schools. But there is no parochial ballot-box. And 
when the ballot-box is established in the schoolhouse, the fact 
is declared and reaHzed that this is a common building, a 
centre of public organization and expression. 

See some of the immediate practical results of using the 
schoolhouse as the polKng-place, results having to do with the 
improvement of this institution on lines of public-health 
service. 

Voting in the schoolhouse implies making the school prin- 
cipal the voting clerk of the district. He or she is at once 
brought into official direct contact with the adults of the 
community. This added function implies some increase in 
salary and increase in dignity and influence. The building is 



I06 EDUCATIONAL HYGIENE 

soiled by Its use for voting, and the splendid Emersonian 
principle that ''things are good if they are only bad enough" 
is, as Health Officer George W. Goler, of Rochester, has said, 
brought into play. The building was dirty as a result of the 
children's use, but it wasn't dirty enough to necessitate thor- 
ough cleaning and renovating. Its use as a polling-place 
points this necessity, and the result is that the building is 
cleaned. The citizens of the district coming to the school- 
house see its architectural ugliness and its poverty of equip- 
ment; and its use as a polling-place, the real headquarters 
of government in a democracy, tends to its improved archi- 
tecture. The vitahzing influence of this use of the school 
building for the primary expression of citizenship upon the 
civic training of the children is obvious and fundamental in 
its importance. 

Deliberative Associations. — ^The next step in social-centre 
development is the organization of the citizens of each dis- 
trict whose names are recorded upon the voting register at 
the polling-place, now established in the schoolhouse, into a 
deliberative association to use the school building as the dis- 
trict common-council chamber, the headquarters of presenta- 
tion and discussion of public questions. This implies the 
service of the school principal or of an associate as the dis- 
trict clerk or secretary of the citizenship in its assembling for 
discussion. The school man, hitherto a man among women 
and children, becomes a man among men; the agent of the 
citizenship in the instruction of the children comes to be forti- 
fied in his influence by his relationship of direct service under 
the citizenship as the civic secretary. And a more present- 
minded, capable man or woman is made necessary for this 
position. The schoolhouse becomes the place of frequent 
assembling of the adults of the neighborhood. As such its 
architectural character and its physical equipment depend not 
only upon the generosity but upon the self-interest of the 
citizens. The organizing of contemporary public problems 
into a curriculum of self-education through discussion by the 



SOCIAL CENTRE AND EDUCATIONAL HYGIENE 107 

citizens, sets a vitalizing standard of government-in-action 
to which the civic training of the children becomes a real ap- 
prenticeship. 

Self-Govemiiient Clubs. — Then comes the organization 
of the boys of the community, the boys between school age 
and majority, into a self-governing club, modelled upon, or 
rather patterned after, the adult civic organization. This 
.imphes the companionship of a club director, which work be- 
comes a function of the school principal or of a member of 
his staff. It impHes the interest of another great section of 
the community, the youth, who may be counted upon always 
to favor improvement — their interest and ambition for better 
architecture and equipment. And the connection between 
the children and the adults, the connection between appren- 
ticeship and the actual practise of citizenihip, is made and 
strongly made for the children by setting before them, in 
the practise of the older boys, training in self-government. 

What is true of this provision of the schoolhouse as the 
assembhng-place of the boys who are above school age but 
have not yet reached twenty-one, as to its need and value, 
is true of its use as the meeting-place of the neighborhood 
club of girls between school age and adulthood. 

Incidentally, this use of the schoolhouse as the club-house 
for the older boys and for the older girls of the district pro- 
vides the machinery and the opportunity for their instruc- 
tion in matters appropriate to their age, matters particularly 
of public health and personal hygiene. 

Weekly Meetings. — Next comes the use of the schoolhouse 
as the weekly gathering-place for general neighborhood as- 
sembling. With one evening in the week devoted to the 
gathering of citizens for presentation and discussion of public 
questions, one evening centred upon the boys' club meeting, 
one evening given up to the girls' club meeting, and along 
with these an evening when old and young gather for a 
programme which begins with the orchestral music provided 
by the neighborhood orchestra that is bound to get itself 



Io8 EDUCATIONAL HYGIENE 

formed to meet this need, and then a half-hour of communal 
singing and then a lecture or entertainment or motion-picture 
exhibition, closing with an hour's dancing of young people 
and older people together, with ideal, homehke chaperonage, 
the basic organization for social-centre development is com- 
pleted. 

Obviously for the arrangement and promotion of such 
general neighborhood evenings the service of a member of 
the school staff, whether the school principal or an associate, 
is necessary, and obviously the inclusion of this function in 
the ofhce of school man or school woman means the socializ- 
ing and warming and elevating of that office. Obviously, 
also, it tends powerfully toward the improvement of the 
architecture and equipment of the building, for this improve- 
ment becomes a matter of citizenship self-interest instead of 
depending merely upon generosity. And plainly this use of 
the schoolhouse as a centre of neighborhood assembling and 
attraction will tend to influence, to vitalize, and humanize 
the curriculum of the children's instruction there. 

The Social Centre as a Health Agency. — The machinery 
is now estabhshed for attacking the problem of public health 
and all other public problems after a constructive and demo- 
cratic fashion. 

In the forum of the citizens, the imperative need of pro- 
viding physical-training opportunities for the community is 
set forth. The outcome is almost sure to be the equipping 
of the schoolhouse and the school-grounds with gymnasia 
indoors and out, and with bathing facilities. 

If medical, dental, and optical service has not already 
begun in the school, the matter of its introduction becomes 
a natural next- thing- to-do, for the use of the schoolhouse as 
the local health ofhce makes a twofold appeal. On the one 
hand, those who are interested particularly in the public- 
health movement see the opportunity that is offered to get 
at the whole community through having health service and 
health instruction centred there; and, on the other hand. 



SOCIAL CENTRE AND EDUCATIONAL HYGIENE IO9 

the opportunity of co-operatively providing for the com- 
niunity's health makes its appeal not only to the parental 
interest but to the selfishness of the citizens. 

And not only is the machinery provided for redeeming the 
medical and pharmaceutical profession of the country by 
identifying the physician's service with education, and so 
realizing the true meaning of * doctor" (which is not pill- 
counter, nor coddler, nor bill-collection worrier, but teacher) ; 
but the machinery is provided for attacking the roots of in- 
dividual and social disease in poHtical corruption, economic 
maladjustment, and leisure-time exploitation — and so ade- 
quately and effectively deaHng with the problem of pubHc 
health.i 

"The Heart of It." — Of the effective pioneers of the 
public health movement, the one whose memory is most re- 
vered in Wisconsin is Frank Avery Hutcliins, founder and 
first secretary of the Wisconsin Anti-Tuberculosis Associa- 
tion, founder and first secretary of the State Free Library 
Commission, organizer and, until his death, secretary of the 
Department of Public Discussion in the University Exten- 
sion Division. The last words of this clear-eyed construct- 
ing engineer of Wisconsin's machinery for social and indi- 
vidual self-enlightenment were spoken in response to the 
news, brought to his bedside, of the estabHshment of the 
schoolhouse as the polling place and community centre, and 
the appointment of the school principal as community sec- 
retary, in one of the small towns of the State. His words, 
whispered with the utmost difficulty, but with -a note of 
profound gladness, were: ''That goes to the heart of it," To 
him ''it" meant the tremendous problem of making the 
public whole — which is the problem of public health. 
1 See Ward's "The Social Center" (Appleton). 



PART II 

THE ADMINISTRATION OF EDUCATIONAL 

HYGIENE 

CHAPTER VII 

THE INITIATION OF A SYSTEM OF EDUCATIONAL 
HYGIENE IN A SCHOOL SYSTEM 

Including a School-Health Survey 

Public Opinion Basis for Public-School Progress. — ^All the 
principles of pedagogy, social psychology, and poHtics, in the 
best sense, figure in the initiation of any or all of the phases 
of educational hygiene in a school system. The prejudices, 
enthusiasms, and social pecuHarities of the community, or 
state, must be taken into thoughtful consideration. The 
superintendent must study the people he is to bring up to a 
higher standard of personal and pubUc hygiene, at least as 
carefully as the teacher must study the children she is to 
educate. PubHc opinion is not a thing to scorn or to disre- 
gard, and it is Hkewise not a thing impossible to build up, 
guide, and make effective in the promotion of the public 
good. We must not thrust educational innovations upon 
people without first helping them to feel the need of them. 
It is far better that through skilful indirect guidance they 
may be led to demand and to work for needed improvements 
than that they get them by imperial fiat from the superin- 
tendent's office or mayor's chair. Here is where probably 
most superintendents fail and where all real leaders of the 
people succeed. The latter know how to create and to guide 
the specific form of desirable public opinion, thus promoting 



no 



INITIATING EDUCATIONAL HYGIENE III 

the self-activity of the community, while the latter work at 
the school as if the school system were in a world of its own 
and the only function of the community were to furnish the 
children and the money, especially the latter. 

David Starr Jordan says somewhere that years ago in 
southern Indiana he came upon the track of a man's influ- 
ence on a community that was as clear and as unmistakable 
as the footprint of a mastodon in the fossil-bearing rock. 
This man had long since passed on, but he had Hfted the 
community to higher levels and standards, and had given to 
it an ineffaceable impress. This man probably knew very 
well in a practical way plain folk psychology, the methods 
of rousing public sentiment, of developing this into specific 
public opinion, and of guiding this onward to public demand 
and public action, including all the factory of local leader- 
ship and availability of special groups. Some one should 
collect from the experience of thousands of teachers and 
superintendents, as well as from the various men and agen- 
cies that have been successful or unsuccessful in the moulding 
of pubHc opinion, the data which when sifted would put into 
the hands of school people a set of principles, richly illus- 
trated, setting forth the guiding lines for success in this field. 
Its relative worth in school-administration courses would be 
very high. We wish here to outline on an empirical basis 
a plan for taking the steps toward school-health progress. 

Steps Toward School-Health Progress 

(i) Getting Informed. — The superintendent should in- 
form himself thoroughly on the principles of the work and on 
what other communities are doing. For this he will need 
some of the best books and pamphlets and a number of school- 
health reports, giving particular attention to cities or regions 
about the same size or smaller than his own. From a pam- 
phlet published by the Sage Foundation he can learn of the 
cities and towns with populations near his own in size that 



112 EDUCATIONAL HYGIENE 

are doing superior work in this field. The reports of the 
national boards of education of England (Whitehall, Lon- 
don) and Scotland (Edinburgh) are always valuable and 
suggestive, and many cities and rural regions that are doing 
able health work can be located by their use, and the local 
reports, say of Bradford, Cambridge, or Dunfermline, may be 
obtained. 

(2) Interesting the Teachers. — ^Next get the teachers with 
you by principals' and teachers' meetings, if your system is 
so large. Rural teachers in non-consolidated schools will 
start directly with the children and people of the community, 
as described in Carney's 'Country Life and the Country 
School." Teachers may be led to procure good school- 
health handbooks to use in reading-circle meetings at the 
buildings. There may be talks by principals, supervisors, 
superintendents, doctors, nurses, or other specialists. Further 
steps in disclosing the local health situation in each teacher's 
room will readily bring, in most cases, enthusiastic response. 

(3) Using the Newspapers. — ^About this time newspaper 
work may well begin, if not earlier. The superintendent should 
see the editors and talk over the health needs of the schools 
and the thing he is trying to accomplish. By interviews, 
articles, quotations from papers, magazines, and books, by 
pictures of conditions both from other places and the local- 
ity, by stories of the findings of the doctors and nurses when 
they begin their work or the findings of the teachers when 
they make their preliminary surveys, much interesting ma- 
terial may be used to get the people to thinking along school- 
health fines and to see to what desirable standards their own 
community should advance. If superintendents and editors 
were as skilful as certain advertisers of chewing-gums and 
safety razors, not to mention other enterprises, the health 
movement in our country would be vastly accelerated. 

(4) School-Health Survey by School Officials.— When 
the teachers realize the importance of more attention to the 
health problem of the schools and community, it is time to 
show them how to do something. Doctor Hoag says in a 



INITIATING EDUCATIONAL HYGIENE II 3 

bulletin of the United States Bureau of Education (555) that 
teachers can without much previous training, but with the 
help of certain detailed directions, diagnose or discover 90 
per cent of the ailments of school-children. The Ohio School 
Survey shows that there are a few limitations to this gen- 
eralization, but that teachers can pick out most of the flagrant 
cases is well demonstrated. I would advise here, then, a 
school-health survey, or census, made by teachers, principals, 
and superintendents, with perhaps some voluntary outside 
assistance. This survey should include: Medical Supervision, 
School Sanitation, Physical Education, and the Teaching of 
Hygiene, and perhaps the Hygiene of Methods, or Instruc- 
tion.^ 

(a) Medical Supervision. — Use here Doctor Hoag's form 
for this purpose as given below and published in the bulletin 
(555) above mentioned, and printed separately ^ as an in- 
expensive folder for the use of schools. The bulletin men- 
tioned may be had from the superintendent of documents, 
Government Printing Ofhce, Washington, D. C. Doctor 
Hoag's Diagnostic Chart for teachers, given in his '' Health 
Index of Children" and in ^'Health Work in the Schools," 
is also valuable for daily use after the survey is over. Snellen 
test charts may be used for vision tests, and principals or 
superintendents may even use the Binet-Simon tests for in- 
telligence for a few selected pupils. When each child has 
been studied by teachers and principals from the health 
standpoint in this way, the results as summarized may well 
be published. Voluntary physicians, dentists, oculists, psy- 
chologists, and neurologists may be called in to verify any 
unusual or serious findings. The parents of children found 
defective should be notified and requested to go to their 
family physician, specialist, or dispensary, to have the teachers' 
findings checked up, and the ailments, if any, treated and 
cured. It is well to be cautious and conservative here, in 

1 Doctor Wood's pamphlet on "Health and Education" (University of 
Chicago Press) will be found very suggestive for each of these five divisions. 

2 By Whitaker and Ray-Wiggin Co., San Francisco, Cal. 



114 EDUCATIONAL HYGIENE 

order that real ailments and defects may be reported, so the 
confidence of the parents may be built up, not shattered. 
If the voluntary work by specialists, as above suggested, 
may be brought in to confirm and to modify the teachers' 
reports, it will be still better. Doctor Hoag's form is here 
inserted: 

AN OUTLINE FOR THE HEALTH GRADING 

OF 

THE SCHOOL-CHILD 1 

BY 

Dr. Ernest Bryant Hoag 

child-study specialist, los angeles, cal., formerly special di- 
rector of school hygiene, minnesota state board of health 

School Date 

Pupil's name Grade 

Teacher's name 

Town or city 

HEALTH GRADING OF THE SCHOOL-CHILD 

(For Teachers or School Nurses) 

Directions for Use 

This plan for the health grading of school-children consists of 
two parts: 

1. An outline for a partial health survey to be made with the 
aid of the pupils themselves, or, in the case of young pupils, with the 
aid of parents. 

2. An outline for a more extensive health survey on the part of 
teachers. 

In schools where a medical officer or nurse is employed this out- 
line will serve as a useful preliminary health survey. 

With the employment of this survey no school need wait for the 
appointment of a medical officer or nurse before commencing some 
effective health work with school-children. 

It is desirable that the teacher should, in the absence of medical 
officer or nurse, make this survey as early as possible after the chil- 
dren enter school, but if necessary the teacher may take her own 
* A four-leaf folder for each child. 



INITIATING EDUCATIONAL HYGIENE II 5 

time and complete the survey of the children in her room at her own 
convenience. 

It is desirable that this survey be made in the case of every child, 
but in any event the teacher should make it in the case of every 
pupil whom she suspects of being mentally or physically unsound. 

The answers obtained to any one question may be of no particular 
significance, but the answers taken as a whole will be of very great 
significance. The answers to questions in the same group are often 
of great importance. For example, it may be discovered that a pupil 
complains of headache, blurred vision, and inability to see easily what 
is written on the board. In such a case the pupil is unquestionably 
suffering .from a more or less serious eye defect. Or, again, it may be 
noted that the pupil complains of earache, running ear, and perhaps 
inability to hear easily what the teacher says. Such a group of sig- 
nificant points would indicate unquestionable ear disease leading to 
permanent deafness. A peculiar standing posture may indicate any 
one of a number of things, for example, spinal disease, weak muscles, 
beginning hip-joint disease, etc. 

The teacher is strongly recommended to mak? these surveys with- 
out attracting the attention of the individual pupil too much to the 
fact that he is under observation. The teacher will soon discover that 
her powers of observation in matters pertaining to the pupils' health 
will be greatly increased and her attention will be called to many 
things of importance which she formerly entirely overlooked. As a 
matter of fact, one of the most important uses of this health survey 
consists in the fact that it trains the teacher's powers of observation. 

When one or more conditions are discovered by the use of this 
survey, which in the opinion of the teacher require attention from 
the family physician, specialist, or dentist, a notice should be sent 
to the parents in the following form: 

Date 

Notice to Parents or Guardians: 

appears to the teacher to be in need of 

attention. A further examination by 

your family physician, dentist, or specialist, is advised. 

Principal. 

School. 

The parent will please sign here and return the notice to the 
principal. 



Il6 EDUCATIONAL HYGIENE 

HEALTH SURVEY 

Part I 

(Questions to be answered by Pupil or Parent) 

Name School 

Date Grade 



Question i. How old are you? 

Answer: 

Question 2. Have you ever had much sickness? Yes No 

Answer: 

Questions. Are you well now ? 

Answer: 

Question 4. Do you eat breakfast every day? 

Answer: 

Question 5. Do you eat dinner every day? 

Answer: 

Question 6. Do you drink coffee? 

Answer: 

Question 7. Do you drink tea? 

Answer: 

Question 8. Do you have your bedroom window open or shut at 
night ? 

Answer: 

Question 9. Have you ever been to a dentist? 

Answer: 

Question 10. Do you own a tooth-brush? 

Answer: 

Question 11. Do you use a tooth-brush? 

Answer: „ . . , 

Question 12. Do you have headache often? 

Answer: „ . . . 

Question 13. Can you read easily what is written on the blackboard? 

Answer: 

Question 14. Does the print blur in your book? 

Answer: , 

Question 15. Do your eyes trouble you in any way? 

Answer: , . 

Question 16. Do you often have earache? 

Answer: 

Question 17. Do your ears ever run? 

Answer: 



INITIATING EDUCATIONAL HYGIENE II7 

Question 18. Can you hear easily what the teacher says? 

Answer : 

Question 19. Is it hard for you to breathe through your nose? 

Answer: 

Question 20. Do you have sore throat often ? 

Answer: 

Question 21. Do you tire easily in school? 

Answer: 

Question 22. Do you work any out of school hours? 

Answer: 

Question 23. What kind of work? 

Answer: 

Question 24. How much ? 

Answer: 



2 
3 
4 
5 
6 

7 
8 

9 
10 



I. 

2. 
3- 
4- 



I. 

2. 



HEALTH SURVEY 

Part II 

(Questions to be answered by the Teacher) * 

A. General Appearance 

Is the child healthy-appearing? 

Is his color good ? . . , 

Is he physically well developed ? 

Is he free from apparent deformities ? 

Has he a good standing posture ? 

Has he a good sitting posture ? 

Are the shoulders even ? 

Does the child walk normally? 

Are the heels of the shoes worn evenly ? 

Is the physiological age of the child apparently 
equal to his actual age ? 



B. Mental Conditions 

Is the child normally advanced in school ? 

Is he mentally alert ? 

Does he answer ordinary questions intelligently ? 
Does he play normally ? 



C. Nervous Conditions 

Is the child good-tempered ? 

Is he free from abnormal emotion ? 



Yes 



No 



* Indicate answers by a check mark. 
Answer as many questions as possible. 



ii8 



EDUCATIONAL HYGIENE 



3. Does he have good powers of muscular co-ordina- 

tion ? 

4. Is the child free from spasmodic movements ?...,.. 

5. Is he free from the nail-biting habit ? 

6. Does he speak without stammering ? 

7. Is he free from pronounced peculiarities such as ir- 

ritability, timidity, embarrassment, cruelty, mo- 
roseness, fits, general misbehavior, etc. ? 

8. Is he apparently free from bad sexual habits ? 

9 . Is he free from so-called ' ' bladder trouble ' ' (requests 

to "go out") ? 

10. Is he usually free from headache? 



Yes 



No 



D. Teeth 



I 
2 
3 
4 
5 
6 

7 
8 

9 
10 



Are the teeth clean-looking ? 

Are the teeth sound-looking ? 

Are the six-year molars in good condition ? 

Has the child been to a dentist within six months ? , 

Are the teeth regular ? 

Does the child use a tooth-brush every day ? , 

Are the gums free from abscesses ? 

Are the gums healthy-looking ? 

Are the upper teeth straight (not prominent) ? . . . 
Have decayed teeth been filled ? 



E. Nose and Throat 

Does the child breathe with the mouth closed?. 

Is he free from chronic nasal discharge ? 

Is he free from "nasal voice" ? 

Has he a well-developed face ? 

Has he a well-developed chin ? 

Has he straight, even teeth? 

Is the child mentally alert ? 

Is he usually free from sore throat ? 

Is the hearing good ? , . . . 



F. Ears 

1. Does the child usually answer questions without 

first saying " What " ? 

2. Is he fairly attentive? 

3. Is he fairly bright-appearing (not stupid) ? 



INITIATING EDUCATIONAL HYGIENE 



119 



4. 

5- 
6. 

7. 
8. 

9- 



I. 

2. 
3- 
4. 
5- 



6. 

7. 
8. 



I. 



Does he have a voice with good expression (not ex- 
pressionless) ? 

Does he spell fairly well ? 

Does he read fairly well ? 

Is he free from complaints of earache? 

Is he free from ear discharge ? 

Is he free from any peculiar postures which might 
indicate deafness ? 



G. Eyes 



Are the child's eyes straight ? 

Is he free from chronic headache ? 

Does he do his work without fatigue ? 

Is he free from squinting or frowning ? 

Is the child free from postures which might indicate 

eye defects, such as leaning over too near the 

desk, holding the head on one side, etc. ? 

Are the eyes free from redness and discharge ? 

Are the eyelids healthy-looking ? ? 

Can the child read writing on the board from his 

seat ? 

Have the eyes been tested separately with the 

Snellen Test Tjrpe ? 



H. Communicable Diseases of the Skin 



Is the head free from any signs of disease (lice, ring- 
worm) ? 

2. Is the skin healthy-looking ? 



I. Eruptive Children's Diseases 

Is the child free from the following general early indica- 
tions of contagious diseases ? 

1. Flushed face 

2. Lassitude 

3. Vomiting 

4. Eruptions 

5. Congested eyes 

6. Discharging eyes 

7. Nasal discharge 

8. Persistent cough 

9. Scratching 

10. Sleepiness 



Yes 



No 



I20 EDUCATIONAL HYGIENE 

The following points often indicate the early signs of transmissible 
diseases in children. They will, of course, not ordinarily be observed 
at the time of making this Health Survey. 

1. Flushed face. 6. Nasal discharge. 

2. Lassitude. 7. Persistent cough. 

3. Vomiting. 8. Scratching of the skin. 

4. Eruptions. 9. Sore throat. 

5. Red eyes. 10. General aches and pains. 
Teachers may use their own judgment about this test. 



Summary 

Physical development , 

Nervous system 

Nutrition 

Mental condition 

Eyes 

Ears 

Nose 

Throat 

Teeth 

Skin 

Eruptive disease 

Food 

Ventilation 

Coffee habit 

Tea habit 



Remarks 



From these individual forms the summaries may be made. 
The standard classification, terminology, code numbers, and 
probable frequency of serious ailments given in Chapter VIII 
may be used for the ailments and defects discovered. 

(b) School Sanitation. — There are several forms on which 
the non-expert person may make a reasonably able survey 
of sanitary conditions. Doctor Ayres gives two brief forms 
in his survey of the Springfield, III, public schools. Other 



INITIATING EDUCATIONAL HYGIENE I2I 

forms will be found in the report of the Ohio School Survey 
and in Bulletin 524 of the Bureau of Education. The chapter 
on School Sanitation Standards in this volume, as well as the 
chapter on Rural School Sanitation, should prove helpful.^ 
These forms are suggestive and the good points of many 
may be put together by the principal or superintendent for 
local use. 

By this means the superintendent may obtain in com- 
pact form the sanitary status of his buildings and grounds. 
If some of the board members can be enlisted to help apply 
modern standards to the buildings included in the survey, 
it may be of strategic importance. If discussion arises, the 
superintendent should have some authoritative text-book on 
school hygiene, including school sanitation, ready at hand. 
Dresslar's book, published by Macmillan, will be found help- 
ful. The survey of the Portland, Ore., school system will 
be suggestive (health phases made by Professors Terman and 
Dresslar).2 

School Sanitation Forms Used by Doctor A3rres 

I. PHYSICAL PLANT AND EQUIPMENT, BUILDINGS 

Building Principal 

Total number of sittings in classrooms 

Seating capacity of assembly-room 

Average attendance: boys girls 

Average enrolment : boys girls 

Classrooms: First floor Second floor Third floor 

Total classrooms 

Has principal room for office ? . . . . Location of assembly-room 

Heating system: hot-air furnace, direct steam, indirect steam 

Thermostatic regulation. ...... Humidification 



1 See the form used by the Philadelphia Board of Health, and the author's 
article on "The Standardization of the Rural School Plant," in School and 
Society, for February 13, 191 5. 

2 The Rural School Hygiene Survey of the Rural Schools of Pennsylvania, 
made by the author, deals with all five divisions. It may be found in the 
Report on Rural Schools, State Superintendent N. C. Schaeffer, Harrisburg, 
Pa., Chairman. 



122 EDUCATIONAL HYGIENE 

Ventilation: window, gravity, plenum fan, exhaust fan 

Location of fresh-air intake Location of cloakrooms 

How ventilated Location of toilets 

Toilets: Number seats for boys Number seats for girls 

Automatic flush 

Number of individual urinals for boys 

Do urinals have automatic flush ? 

Material of walls and divisions of urinals. . . .of toilet floors 

Number feet of urinal trough. . . .Material of urinal trough 

Number of wash-basins Individual soap provided. 

Individual towels 

Number of bubbling fountains. . . .How often are windows washed?. 

System of cleaning employed 

How often are floors washed?. . . .Are floors oiled? 

Stairways of fireproof material?. . . .Are stairways enclosed? 

Material of enclosure .... Hand-rails both sides .... Centre hand-rail , 

Width of stairways: first floor second floor 

Width of steps 

Height of risers .... Width of corridors .... Corridors unobstructed . , 

Fire-escapes: number and kind , 

Signal connection with fire department. . . .Inside hose equipment. . , 

Chemical extinguishers Automatic sprinklers , 

Automatic fire-alarm , 

Heating plant separated by fireproof walls, ceilings, and floors ?...., 

Is buflding of fireproof construction ? 

Of fire-retarding construction ? 

Material of outside walls of building. . . .of floor beams , 

Gymnasium facilities Area of playground 

Area of site Area of space occupied by building , 

Date of construction , 

Sheet S}4 by ii Inches 



II. PHYSICAL CONDITIONS OF CLASSROOMS 

Building Teacher Room No Grade 

Av. attendance . . . .No. sittings: adjustable. . . .Non-adjustable. . . . 

Total 

Length .... ft. Width ft. Height ft. Floor area sq.ft. 

Cubic contents. . . .cub. ft. 

Square feet of floor area per sitting . . . . sq. ft. 

Cubic feet of air space per sitting .... cub. ft. 

Total window area . . . . sq. ft. 

Distance from top of window to floor. . . ,ft. 



INITIATING EDUCATIONAL HYGIENE 1 23 

Square feet of floor area for each square foot of window area sq. ft. 

Windows at left, back, right, or front of children 

Lineal feet of blackboard. . . .ft. Lineal feet per sitting. . . .ft. 

Inches from base of blackboard to floor. . . .inches. 

Do seats project under front edge of desk?. . . .How far?. . . .inches. 

How many pupils cannot easily rest feet on floor ? 

Distance from rear seat to rear wall .... ft. 

Color of walls .... Color of ceilings .... Color of window-shades 

Do shades roll from top or bottom? Has room a thermometer?. . . 

Card 4 by 6 Inches 

(c) Physical Education. — We can call attention here to no 
good forms for investigating physical education. The calis- 
thenics, plays, and games used, their supervision, kinds of 
play apparatus, kind of room calisthenics, two-minute exercise 
drills, games used in the schools, size of school playgrounds, 
athletics and their supervision, proportion^ of student popu- 
lation reached effectively by physical-education department, 
number and training of physical-training and other physical- 
education teachers and supervisors, the extent to which 
physical-education instructors discover ailments and defects, 
school bathing and swimming, athletic leagues, folk-dancing, 
etc., will be considered. Curtis's books on "Play and Rec- 
reation'' and "Education Through Play" will be helpful 
here; likewise the Playground Magazine (No. i Madison 
Avenue, New York City), and a bulletin issued by the State 
Department of Public Instruction of Virginia on Play and 
Athletics, showing desirable home-made apparatus and plays 
and games. Another bulletin on Recreation, by the State 
Department of Education of Oregon, and the bulletin of the 
United States Bureau of Education on Play, are also desir- 
able. Rapeer's "School Health Administration" has a chap- 
ter on this problem. 

(d) The Teaching of Hygiene. — For this we have no good 
forms, although several surveys have considered the matter, 
e. g., those of Ohio, Portland, Ore., and Vermont. This 
would include the kind and quality of text-books used, the 
amount of attention paid to the formation of good health 



124 EDUCATIONAL HYGIENE 

habits, such as cleanliness of person, tea or coffee drinking, 
sufficiency of sleep, ventilation of sleeping-rooms at night, etc., 
as well as attention to the provision of washing faciUties, 
liquid soap, paper towels, toilet-paper, and sanitary drinking 
fountains at schools. It would include the time on the 
daily programme devoted to instruction in hygiene, the 
efficiency of the methods used, and the amount of correlation 
with other subjects. The chapters in this volume on the 
"Teaching of Hygiene" in elementary and high schools, in 
the author's volume on "Teaching the Elementary School 
Subjects," and the May, 191 2, number of the Teachers Col- 
lege Record (Columbia University), on ''Health Instruction 
in the Elementary School," by Professor Reesor, will prove 
helpful. 

{e) The Hygiene of Methods of Teaching and Manage- 
ment. — ^Here we have problems concerning the daily and 
weekly programme as to proper alternation of subjects, 
proper time of day, suitable time between work periods, 
the hygiene of vision, including reading from bad t5^e, the 
placing of children with defective vision and hearing at the 
back rather than the front of the room, etc. They cannot 
be well surveyed at present. Doctor Beik's two chapters in 
this volume will prove suggestive. Professor Terman has a 
volume announced on this interesting topic, namely, "The 
Hygiene of Instruction." Dresslar has a chapter on the 
subject in his "School Hygiene." This division may be 
omitted in the preliminary survey, however, if desired. If 
teachers, principals, and superintendent do their work well 
with the first four phases of the survey of educational hy- 
giene, much will be accomplished. 

(5) Public Co-operation. — When the school people have 
submitted themselves, their pupils, and their environment to 
such scrutiny, in the light of the school-health standards 
available, they can proceed to do much along all five lines of 
educational hygiene without calling upon the board for ex- 
penditures of money. However, their work will necessarily 



INITIATING EDUCATIONAL HYGIENE 1 25 

be somewhat faulty, especially along medical lines. Parents 
can be visited in the homes by teachers as well as by nurses, 
of course, but the training of the nurse and the fact that 
she is a nurse, or is called ''nurse," will give her an advan- 
tage. The examination by a physician, especially with the 
parents present, adds much to the effectiveness of the work 
of medical supervision. Then, too, in cities above 10,000 
population there is need of a single school health supervisor 
who can supervise all phases of educational hygiene. 

At this stage, then, it is desirable to have direct public 
co-operation for instituting a trial nurse, doctor, school den- 
tist, all at once or in pairs. Most school features have been 
initiated in this manner, namely, first a trial on a limited 
scale paid for and inaugurated by private groups or individ- 
uals; demonstrated success, or general conviction that the 
feature is desirable as a part of pubKc-schoolVork; and, third, 
the adoption of the measure and its support by pubHc taxation. 

Here a strong parent-teachers' organization, or several 
of them, may be formed to promote this work. Dues may be 
charged and donations collected. Women's clubs and vari- 
ous private organizations may be appealed to in various 
ways. Elsa Denison's book on "Helping School Children" 
and Mrs. Cabot's book on ''Volunteer Help to the Schools," 
as well as Mr. Perry's chapter in this volume and his book on 
*'The Wider Use of the School Plant," will be of great as- 
sistance here. Dresslar's chapters in the 191 2 and 19 13 
Reports of the United States Commissioner of Education 
will also give much help. The superintendent should make a 
survey of the city to discover all possible individuals, groups, 
and organizations that will help. Sometimes national bodies 
can be called in to assist without expense, and at other times 
the business men's club or commercial club will take the 
matter up, as the Chicago Club has the matter of vocational 
education. Such an investigation need not take long. The 
idea is democratic advance through public awakening and group 
initiation oj new measures — genuine school leadership. 



126 EDUCATIONAL HYGIENE 

• • 

(6) Volunteer or Partly Paid Specialists. — ^Along with 
this will come the appeal to the dentists', physicians', and 
nurses' organizations for voluntary or partly paid work in the 
schools. A group of physicians can often be procured each 
individual of which will offer his services for a certain number 
of two-hour periods during the year on a schedule made by 
the superintendent, the latter to notify each physician ahead 
of time. The same may be done for nurses and dentists. A 
nurse may be loaned for part time by the visiting nurses' or- 
ganization while the other part of the time may be paid for 
by the school associations from the voluntary fund. If possi- 
ble, a full-time nurse should be employed to begin with. Later 
a part-time physician may be employed. One nurse for each 
1,500 pupils and one physician two hours a day for each 2,500 
pupils are good standards. 

(7) Public Adoption. — Through this volimtary demonstra- 
tion the ground has been broken for the final step of school- 
board support. With the public aroused and acquainted with 
the facts, with constant newspaper articles and pictures, 
with budget exhibits and play pageants, with records of 
lowered retardation and ehmination figures, and fewer cases 
of disease and death, most boards will move forward to oc- 
cupy the ground broken by private initiative, led by the 
superintendent. Such leadership is real statesmanship and is 
of a far higher type than the more obvious kinds often going 
on under the name of politics/war, diplomacy, and the like. 



CHAPTER VIII 

THE GENERAL ADMINISTRATION OF EDUCATIONAL 

HYGIENE 

Facing the Health Issue. — The general health problem, 
which has been sketched in previous chapters from the stand- 
point of social economy, has in a more or less vague way, 
during the last decade, been rapidly rising in the national 
consciousness. Leaders in great numbers in all parts of the 
country have rather suddenly awakened to the fact that 
the most important human asset we possess is being wasted 
and destroyed in the most thoughtless manner, and that the 
most important kind of conservation of natural resources in 
which we in America may engage is that of the conservation 
and development of our national health and vitaHty. The 
progress of science has developed in many and marvellous 
ways an unparalleled array of instrumentahties for over- 
coming death, disease, and physical imperfection. Where 
we once sat in darkness and shivering fear at the terrible 
mysteries which robbed us of Hfe, health, and happiness 
there is now an increasing Hght. The work of Pasteur, of 
Koch, of Reed, of Galton, and many other scientific students 
of Hfe and health has borne glorious fruit not only in remark- 
able additions to human knowledge but in an increasing 
number of men and women working in the laboratories of 
life wherever the problem of health and vitahty may be con- 
cretely and intimately met and studied. 

By these various means we have come to the amazing 
spectacle of an enHghtened people in need of these health 
principles in their daily life and practise and yet from ten 
to forty years, in general, behind the chariot of Truth drawn 

127 



128 EDUCATIONAL HYGIENE 

forward so rapidly by the small number who are her devotees. 
The new health science is produced and kept in the pos- 
session of but a very few, while the old mores and customs of 
the people remain largely untouched. To make this knowl- 
edge common property and daily, living practise, to create 
and foster more agencies for learning the truth regarding 
health and vitality, and to discover how new health standards, 
ideals, and practises may be so inculcated in the daily hves 
of the many as appreciably to improve the health and vigor 
of our nation — these are the problems of educational hygiene. 

Public-Health Improvement. — In these few early years 
of the twentieth century, as suggested, the anomaly here 
presented has been sensed by many leaders in many Knes of 
work. Newspapers and magazines have taken up the problem, 
public opinion has been in many places aroused, and the 
public-health spirit, which has been dormant throughout the 
long health dark-ages since the early Greeks revered Hygieia, 
has come by a new birth again into its rightful position among 
the values of life. The first vague stirring of this new health 
spirit has been evidenced in a most interesting and excep- 
tional heterogeneity of efforts directed toward the discovery 
of the specific nature of our health problems and the best 
methods of solution. The playground movement, the anti- 
tuberculosis campaigns, the movement toward registration of 
births and deaths, the various health philanthropies of an 
investigative and curative nature, such as those of Rocke- 
feller, Forsythe, Sage, Carnegie, and many others, the school- 
medical-inspection movement — these, and hundreds of others, 
have in infinite variety sprung up spontaneously to fight down 
the enemies of health. 

In the schools these various health and development 
measures have been introduced by many agencies for many 
purposes. At present they appear to many as a host of 
uncorrected, poorly manned, and poorly directed agencies, 
little beyond the stage of miscellaneous fads. There is, for 
example, the present great and important interest and effort 



ADMINISTRATION OF EDUCATIONAL HYGIENE 129 

along the line of the psychological examination, treatment, 
and education of mentally deficient or exceptional children; 
there is the movement for better school sanitation, including 
better ventilation and Hghting, the aboHtion of common 
drinking-cups and common towels, etc.; the provision of 
playgrounds for all children; the creation of school clinics, 
and medical inspection and examination; and many others. 
The onlooker who sees these agencies as miscellaneous, weak, 
uncorrected, and largely inefficient undoubtedly sees them 
aright, for these adjectives truly describe them. As such, the 
situation furnishes us a social emergency. For the danger is 
that the first weak and halting steps in any of these various 
directions may be taken as permanent standards, as has so 
often happened; also that the development may be one-sided 
and faddish, that important agencies wilUlanguish and die 
out, that the work may be wasteful and expensive, and that 
the whole health movement, now so promising, may largely 
fail because it has not risen to the hopes and needs of the times. 

School-Health Principles. — The efficiency of these various 
agencies in the schools is the topic of this chapter. Scien- 
tific management in business, the success due to organization 
and correlation of scattered parts in great corporations, the 
supreme importance of supervision and leadership as well as 
professionally trained workers in the schools, and the scien- 
tific and democratic needs and tendencies of the times, all 
furnish suggestions for lowering the cost and increasing the 
efficiency of school-health work. Some of the important and 
essential principles seem to be as follows: 

(i) School health and development work is a specialty 
and must be placed in the hands of those specially educated 
for this service. This, however, will not displace, but make 
more efficient, the teachers, principals, and supervisors. 

(2) The various phases of school-health work must in 
each school system be organized into a single department 
centred on the solution of the school-health problem. 

(3) The professional training of teachers must henceforth 



130 EDUCATIONAL HYGIENE 

include, as at least correlative with educational psychology, 
the study and practise of educational hygiene. 

(4) These teachers and the doctors, nurses, dentists, 
oculists, and psychologists must have expert leadership and 
supervision. 

(5) The adult public must be educated through the 
schools; and, finally, 

(6) The parents and general public must be helped as 
never before to co-operate for school-health progress, not 
only for the sake of the children and the schools, but for 
their own educational participation. 

The Divisions of Educational Hygiene. — ^We cannot here 
support at length these generahzations. To a large extent 
they seem self-evident to any one acquainted with the actual 
conditions in the schools and the actual successes of many 
able educational and other leaders. They are fairly general 
principles underlying the success of practically any public 
agency in a democracy. Of all agencies the pubHc-school 
systems of the country should for many and sufficient reasons 
be most democratic and most efficient. We shall attempt in 
the following pages and chapters to sketch broadly the 
methods by which the various factors may be correlated in 
the service of school and national health. 

Now, what are the more immediate ends to which the 
schools should direct their efforts in this work? We might 
give a Kst such as fresh air, good food, sleep, clothing, sun- 
Hght, recreation, freedom from maHgnant germs, etc. A 
number of organizations of these health factors might be 
made. Burk's book on "Health Work in the Schools" has 
something of the above outhne. Of the many possible we 
choose the following because of its simplicity, its practicability, 
and its ease of introduction, namely: 

(i) Determining the actual physical and mental nature 
of the children as measured by the normal or typical, with 
necessary remedial measures. This will practically mean a 
health census of school-children, with special reference to the 



ADMINISTRATION OF EDUCATIONAL HYGIENE 131 

pathological, actual and incipient, and to the exceptional. 
This division will determine the actual physical condition of 
children and attempt to get them placed in normal condi- 
tion. The best name for a division to work in this field yet 
suggested seems to be that of Medical Supervision. 

(2) Providing a hygienic school, home, and community 
environment. On the basis of what is learned of the physical 
nature of children there can be gradually developed for them 
an environment that will promote health and normal physical 
development. The best name at present for this division is 
the common one, School Sanitation. 

(3) Providing for the development of splendid bodily 
resistance and a healthy, happy body and mind, including 
medical gymnastics, play, physical training, certain forms of 
recreation, and others. The best name for this division ap- 
pears to be Physical Education. 

(4) When we have learned the actual physical condition 
of the children and have put them into fairly normal con- 
dition, after we have provided a hygienic environment for 
them, and after they are provided with wholesome physical 
education, then there comes a fourth division devoted to 
teaching the pupils the principles, the ideals, and many of 
the habits of health. This division may be termed merely the 
Teaching of Hygiene. 

(5) But more is needed than medical supervision, school 
sanitation, physical education, and the teaching of hygiene. 
We may put the children into good physical condition, in a 
hygienic environment; we may furnish them with excellent 
physical education, and provide skilled teachers of hygiene; 
and yet the methods of handUng the children, the methods of 
teaching, examining, training, and curing, may be such as 
to promote worry, exhaustion, fear, and many other unhy- 
gienic symptoms. A neurasthenic and *' cranky,'' though 
scholarly, teacher may injure the health of children by bad 
methods. This division deals with the hygiene of methods, or 
as it is commonly termed, perhaps, The Hygiene of Instruction.^ 



132 EDUCATIONAL HYGIENE 

The plate accompanying gives a rough idea of this organ- 
ization. 

Now, when we have analyzed out these five functions 
and created divisions of effort and attention to promote 
them, we have a fairly complete organization. Some may 
object to the placing of the work of the clinical psychologist 
imder medical supervision. However, this is a picture of the 
actual development now going on in this country and abroad, 
and seems based on good scientific and practical grounds. 
When, perhaps, the use of the Binet and other tests of in- 
telligence, the special classes for mentally subnormal and 
mentally gifted, and the whole clinical psychology technique 
is better developed and manned than at present, there will be 
created in many large school systems this separate division 
as an actual, outward reality.^ We leave it, however, for the 
present with the medical supervision in the confidence that 
the physicians, dentists, nurses, and psychologists can work 
together very well in the service of the exceptional, or sub- 
normal, children, physical and mental. 

It may also be said that the Hygiene of Teaching belongs 
here as a separate division. This is the hygiene of an occu- 
pation, teaching, and it is of great importance financially 
and educationally and much neglected. Terman has em- 
phasized it in his little book on ^'The Health of the Teacher." 
But the teacher needs all that the pupils need: medical ex- 
amination periodically, any necessary treatment, physical 
education, especially recreation, a healthful environment in 
which to work, education along the lines of health, and such 
supervision and administration as will promote her best 
work and health, not their opposites as so often happens. 
Through the efforts of the Life Extension Institute many 
business organizations are using similar methods of guarding 
the health of their workers. The State is even more bound 
to exercise such care. Teachers, janitors, and others, then, 
may be dealt with in the five divisions given. In short, these 
five divisions seem practically and scientifically justified. 
^ As in St. Louis and certain other cities. 



THE DIVISIONS OF EDUCATIONAL 
HYGIENE 

Supervisor of Hygiene 



MEDICAL 
SUPERVISION 



SCHOOL 
SANITATION 



PHYSICAL 
EDUCATION 



NURSES AND 
DOCTORS. 

INSPECTIONS 
AND ANNUAL 
EXAMINATION'S 



DISCOVERING 

HEALTH 

NEEDS. 

CO-OPERATING 
WITH BOARDS 
OP HEALTH 
AND PRIVATE 
ORGANIZA- 
TIONS. 

OPEN AIR 
SCHOOLS. 

LIMITING 
DOCTORS TO 
EXAMINA- 
TIONS, 

SUPERVISION 
OF NURSES 
AND WORK 
IN CLINICS. 

PSYCHOLO- 
GISTS, 
OCULISTS. 
SURGEONS, 
DENTISTS. 
PHYSICIANS. 

SUPERVISION 
OP SCHOOL 
FEEDING. 

SCIENTIFIC 
STUDIES OP 
PREVENTION 
AND CAUSE 
OP. DISEASE. 

CAREFUL 

RECORDS 

EMPHASIZINff 

SERIOUS 

AILMENTS 

FOUND AND. 

CURED. 

TRAINING 
SCHOOL 
NURSES FOR 
ALL INSPEC- 
TION AND 
EXAMINATION. 

NURSES AS 

ATTENDANCE 

OFFICERS. 



OFl<lCh;i 



SCHOOL SITES 
AND ARCHI- 
TECTURE. 

VENTILATION. 



DRINKING 
WATER AND 
FOUNTAINS. 

SCHOOL 

CLEANINQ, 

VACUUM 
CLEANERS, 

SCHOOL 
BATHS. 

HYGIENIC 

TOILET 

FACILITIES. 

SCHOOL SEATS 
AND DESKS. 

DECORATION. 

THE STAND- 
ARD SCHOOL 
ROOM. 

FIRE-PROOF 
CONSTRUC- 
TION. 

HEALTH. REST. 
AND EMER- 
GENCY ROOMS. 

PLAYROOMS 
AND ROOF 
PLAYGROUNDS. 

OPEN WINDOW 
ROOMS. 

SUPERVISION 
OP JANITORS. 

HYGIENIC 
CLOAK ROOMS. 

DRYING AND 

WARMING 

SEATS. 

INVESTIGA- 
TIONS OF RE- 
CIRCULATION, 
HUMIDITY, 
AIR-CLEAN- 
ING, DISIN- 
FECTION, ETC. 



PLAY AND 
PLAYGROUNDS. 

PHYSICAL 
TRAINING 
AND GYM- 
NASTICS. 

MEDICAL 
GYMNASTICS. 

ATHLETICS 
AND LEAGUES. 

POSTURE AND 
CORRECTIONAL 
EXERCISES. 

ASSISTING 
IN MEDICAL 
SUPERVISION. 

RECREATION. 

SCHOOL 
EXCURSIONS 
AND TRAMPS. 

BOY SCOUTS 

AND CAMP 
FIRE GIRLS. 

GYMNASIUMS 
AND ATHLETIC 
FIELDS. 

SV/IMMING 
AND BATHING. 

POOLS, SHOW- 
ERS AND 
BELA.CHES. 

FOLK 
DANCING. 

PHYSICAL 
EDUCATORS 
WITH MEDICAL 
KNOWLEDGE. 

HIGH SCHOOL 
CADETS. 

CLASS ROOM 
GAMES. 

PAY FOR 
SUPERVISING 
PLAY AFTER 
SCHOOL AND 
SATURDAYS. 

CULTIVATING 
THE GREEK 
IDEAL OF 
PHYSICAL 
AND MENTAL 
PERFECTION. 



HEALTH EDU- 
CATION OP 
TEACHERS. 

ADVISING 
CHOICE OP 
BEST HYGIENE 
TEXTS AND 
TOPICS. 

FORMING 

personal 
Hygiene 

HABITS. 

PUBLIC 
HYGIENE 
STUDY AND 
CO-OPERATION. 
HEALTH Eiai- 
CATION OF^ 
PARENTS. 

FEEDING, 
CLOTHING 
AND SLEEP 
OP CHILDREN. 

HOME tlYGIENE 
IN DOMESTIC 
SCIENCE. 

VOCATIONAL 
HYGIENE IN 
INDUSTRIAL 
SUBJECTS. 

TALKS BY 
DOCTORS, 
NURSES AND 
SPECIALISTS. 

FIRST AID. 

SEX HYGIENE. 

STUDYING 
COMMUNITY 
HEALTH 
PROBLEMS 
AND METHODS 
OP IMPROVE- 
MENT. 

DAILY ORAL 
QUESTION- 
NAIRE ON 
HOME 
HYGIENE : 
USE OP 
TOOTH-BRUSH, 
COFFEE 
DRINKING, 
VENTILATION, 
ETC. 
HEALTH 
KNOWLEDGE, 
HEALTH 
IDEALS, 
HEALTH 
EFFICIENCY. 



"THE? HYGIENE 
OF INSTRUC- 
TION." 

FATIGUE, 
OVER-WORK 
AND UNDER- 
WORK. 

THE TYPE OP 
BOOKS. 

THE HYGIENE 
OP SCHOOL 
SUBJECTS. 

INTEREST AND 
ATTENTION. 

INTER-RECI- 
TATION RE- 
CREATION. 

TRANSFORM- 
ING -NEURAS- 
THENIC AND 
"CRANKY- 
TEACHERS. 

MOTOR 
ASPECTS OP 
TEACHING. 

THE GOSPEL 
OP WORK. 

THE HYGIENE 
OP JOY IN 
SCHOOLS. 

PREVENTING 
PHYSICAL 
DEFECTS AND 
PATHOLOGICAL 
CONDITIONS. 

SCHOOL 
PROGRAMS. 

PART-TIME OR 
WHOLE-TIMS. 

INFLTTENCB 
OP VACA- 
TIONS AND 
HOLIDAYS. 

HEALTH IN- 
DIVIDUALITY. 

HYGIENIC 
EFFECTS OP 
DIFFERENT 
METHODS. 

THE TEACHER 
AS MEDICAL 
GUARDIAN. 



134 EDUCATIONAL HYGIENE 

We have now an organization of the field of educational 
hygiene. How are we going to get these various phases of 
the service to work together with the greatest efficiency and 
the least expense? How are we to provide the expert super- 
vision and service which we have named as essential? With- 
out going into the detail desirable, and attempting to avoid 
the pitfalls of devising a general cure-all for all kinds of school 
systems, we offer for consideration the following plan of ad- 
ministrative organization: 

The Administration of Educational Hygiene: A Tenta- 
tive Standard Plan. — School superintendents are not special- 
ists in the field of educational hygiene. Their education has 
generally been very much lacking in training along the lines 
of the physical, rather than the mental, nature of children, 
and most of the various health measures have come into the 
schools because of pressure by organizations and individuals 
from without school systems. The average superintendent 
probably spends very much less than one per cent of his time 
in studying and superintending school-health work. As there 
have been added in most progressive school systems super-* 
visors of the various special phases of school work, so there 
must be supervisors of educational hygiene. In the past, and 
to a large extent at present, we have supervisors and teachers 
of physical training, and supervisors and instructors for play- 
grounds; doctors and nurses are rapidly being added ;^ dentists, 
oculists, dermatologists, psychologists, and surgeons are being 
provided. The regular teachers need education and inspira- 
tion along the Knes of health work. There should be, then, 
a specialist in the schools to co-operate with and to lead the 
many civic and other bodies that have or may take a part 
in school-health work. All these needs and heterogeneous 
agents furnish the problem for organization and scientific 
management. 

1 The Bureau of Education reported in 1914 that of 1,300 cities with a popu- 
lation of 2,500 to 30,000 inclusive 516 cities report medical-inspection systems, 
and that 86 of the 516 have one or more school nurses. 



ADMINISTRATION OF EDUCATIONAL HYGIENE 13 5 

The only one who can adequately organize, supervise, and 
make efficient these miscellaneous instrumentahties and 
agents must be the educational hygienist. The educational 
hygienist should be one who knows well and can successfully 
supervise all the manifold phases of school-health work. The 
average physician is little versed in pediatrics, and not at all 
in school work and the phases of educational hygiene outside 
of mere medical inspection. The average physical-training 
teacher or supervisor knows something of her subject, but 
little more. The educational hygienist must know the 
schools and their problems; he must either be a physician 
skilled in the field of children's diseases and child hygiene, or 
an educator who has had such study and experience in the 
fields of school sanitation, sociology, the phases of medical 
training which may function in school medical supervision, 
in physical education, and, perhaps, in th^ two remaining 
divisions of educational hygiene, as will enable him to super- 
vise all school-health work. The ordinary medical course is 
a very poor training for such work. We need a four-year 
course that is designed especially to develop educational 
hygienists. Such a course may be provided in connection 
with some progressive college for the training of teachers, 
such as Teachers College, Columbia University, which is 
now purely a graduate institution, in some good medical 
school, or in connection with the courses that are now pro- 
vided at the University of Wisconsin, at Cambridge, Eng- 
land, and elsewhere, to educate doctors of pubKc health — 
D.P.H. A teachers college near and connected with a medical 
school would make a very desirable combination. 

Not having such training courses as yet, we should take 
physicians who have had experience in physical education, 
physician-physical-educators, or take educators who have 
had the elements of a medical education and who are versed 
in physical education, including normal diagnosis, medical 
gymnastics, play and playgrounds, and so on. The average 
physician has almost as far to go in perfecting himself for 



136 EDUCATIONAL HYGIENE 

this work as has the educator. In an effort to provide such 
educational hygienists for several cities and State depart- 
ments of education the writer has found in this country over 
twenty available physicians who have had sufhcient experi- 
ence in physical education and school work to make success 
possible in this new field. Several cities, such as Boston, 
Albany, Minneapohs, New York, and others, have such men 
as supervisors of hygiene for the schools, and a number of 
State departments of education are looking forward to pro- 
viding such officers. The State Board of Health of Minne- 
sota employed for some time such a hygienist, Doctor Hoag, 
who has a chapter in this volume and whose report of this 
work is printed by the United States Bureau of Education. 
As soon as universities estabHsh chairs and departments of 
educational hygiene, similar to those established at Clark, 
Stanford, and Teachers College, Columbia University, and as 
soon as more cities and rural regions demand such school- 
health officers, we shall have forthcoming a sufficient supply 
of eager and qualified young men. 

Such an official could be made co-ordinate in rank with 
other supervising officers under the general superintendent of 
schools, and could in many places so reduce school expenses 
as to save his own salary. The salary of such men must be 
between two and four thousand dollars, alrnost the salary of 
superintendents. Such an official, however, can frequently 
do the work of several part-time physicians, or medical ex- 
aminers or inspectors; he can frequently take the place of one 
or more physical- training teachers or supervisors; he can di- 
rect athletics and summer playground work, evening recrea- 
tion centres, and public-school athletic leagues; he can fre- 
quently direct the school nurses in such a manner as to 
ehminate one or more special truant officers; and he can make 
the work of the whole health and development corps more 
efficient, efiminating waste, testing results, cutting down 
exclusions and illness-absence, and consequently retardation, 
elimination, and non-promotion. The health of the children 



ADMINISTRATION OF EDUCATIONAL HYGIENE I37 

of the schools and nation will not be adequately preserved 
and developed until such a definite organization and such 
health leaders are incorporated in school systems. Efficient 
leadership furnishes that scientific management, inspiration, 
and breath of life necessary in all successful social organiza- 
tion, and the school cannot afford longer to miss its advantages 
in the fundamental field of health. 

The United States Bureau of Education and the English 
and Scottish National Boards of Education at present have 
such supervisors of educational hygiene, the last two being 
physicians and the first not. France, Germany, and Sweden, 
especially the last, have gone a long way in this direction. 
The State Commissioners of Education in Massachusetts 
and New Jersey have both recently made efforts toward 
getting such officers added to their departments for State 
supervision. The demands of economy, hi leadership, and of 
efficiency will soon force most other States and most cities, 
as well as many rural regions, to supply such officers. 

Boards of Education, not Boards of Health. — This work 
must be placed everywhere, except perhaps in certain rural 
regions for a time, in the hands of the boards of education, 
not of the boards of health. I have treated this problem at 
some length in "School Health Administration," examining 
all sides of the question. Efficiency cannot come through ad- 
ministering any part of the school's work for children by some 
outside agency. Statistics and experience prove this; and the 
tendency is everywhere toward placing the work in the hands 
of the boards of education. Doctor E. H. Lewinski-Corwin 
has shown that a great factor in the success of medical super- 
vision is the degree of co-operation which the medical and 
health officials obtain from the teaching corps.^ Such co- 
operation can never be generally attained with this work 
in the hands of boards of health. Many other facts in the 

1 "The Practical Necessity of School Clinics," an investigation of the treat- 
ment of school-children in New York City, in the Popular Science Monthly for 
May, 1914. 



138 EDUCATIONAL HYGIENE 

situation favor the school's administration of this work, while 
few favor board-of-health control. 

Scientific Organization with Little Increased Expense. — 
As stated above, the expenditure for such a supervisor of hygi- 
ene, in cities that already are doing their duty to the children in 
the hne of health, with school doctors, nurses, and physical- 
training teachers, frequently may require Httle or no addi- 
tion to the present school budget, the work being merely 
that of reorganization of the various health provisions which 
have, in various ways and for several years, been coming 
into the school systems. In all but the largest cities the 
director can take the place of one or more part-time physi- 
cians, and can also do the work of one or more supervisors, 
or teachers, of physical training in the elementary schools. 
Money can also be saved as suggested by having him direct 
the summer playground work which now costs a number of 
cities considerable sums, the school clinic or clinics when 
started, high and elementary school athletics, evening recre- 
ation, and a number of other savings which may go to make 
up his salary. The nurses, when so directed, may take the 
places of attendance officers in many cities, and so save an- 
other considerable item. 

The present expenditures in these fields and the reorgan- 
ized expenditures have been given for twenty-five cities in 
** School Health Administration. 'V Most cities have not yet 
caught up with the school-health needs; but most cities of 
average size can secure such departments of hygiene for little 
over 2 to 2, P^^ cent of current school expenditures. In many, 
the added expense will, as suggested, be inconsiderable. 

For further concreteness, the old and the new reorgan- 
ized expenditures, for a fairly typical city already possessing 
the elements of such a department, are here given. This 
city has a population of about 50,000; there are fifteen schools, 
a public-school average enrolment of 6,000 pupils; and an- 
nual current expenditures amounting to about $250,000. 



ADMINISTRATION OF EDUCATIONAL HYGIENE 139 



OLD, UNCORRELATED SYSTEM 

2 high-school teachers of physical training $2,200 

2 elementary-school teachers of physical training 1,800 

6 physicians, two one-hour school visits weekly, at $300 1,800 

3 school nurses, 44 hours a week, at $750, ten months 2,250 



Total. 



;050 



REORGANIZED, DIRECTED SYSTEM 



1 supervisor of hygiene, full time, 11 months $3,000 

2 high-school teachers of physical education 2,200 

I assistant physician, two hours a day, ten hours a week 400 

3 school nurses, 44 hours a week, 2 at $825, i at $750 2,400 

Total $8,000 

Here we have the new organized and directed system 
at less than the original cost. There remain $50 toward 
more efhcient records and blank forms. We have deducted 
nothing for saved expenditures for attendance officers, play- 
ground direction, etc., nothing but five unnecessary part-time 
physicians and the two elementary teachers of physical train- 
ing. Where the latter officials are paid less in the old system 
and the supervisor $2,500 instead of $3,000, there is another 
balancing of expenditures. The point is that the added ex- 
pense need not be great. 

The third nurse may not be added the first year, which 
would give a further reduction of $750. Perhaps scientific 
management may make her permanently unnecessary in 
many cities. The tendency is, however, in the other direction. 

The supervisor can, with the daily help of one 6i the 
two or three nurses, for two hours a day, examine the same 
number of children as the assistant physician, 3,000; and 
he can call the teachers together by grades and teach them 
how to carry on the physical- training work at the schools; 
and can take part of each day in supervising their work. 

The assistant physician is paid $100 more a month, and 



I40 EDUCATIONAL HYGIENE 

gives two full hours in one school daily. With the assistance 
of one of the nurses he can examine during the school year 
the other half of the school population (3,000 pupils), and 
can help make such inspections as are necessary. The third 
nurse, if employed, is left free for individual and classroom 
inspections and for follow-up work. Neither the teachers 
nor the physicians are bothered with vision and hearing tests, 
the nurses making them; and practically all clerical work 
connected with medical supervision will also be done by the 
latter. The physicians will be free for technical medical work, 
and the teachers will be less interrupted. 

Two of the nurses are paid for an extra month in the 
summer, one for July and one for August, to follow up cases 
not cured at the end of the school year and for necessary 
inspection of children at summer schools and playgrounds. 
Some of the most valuable work now being done by nurses 
is accomplished in these summer months; and the number 
of skin, parasitic, and infectious ailments is very much less 
at the opening of the next school year. 

The two high-school teachers of physical training, one a 
man and the other a woman, are left at perhaps the same 
salaries ($1,300 and $900). 

The supervisor of hygiene gives his entire time to the 
work, not for ten but for eleven months. If he obtains a 
thoroughly good assistant school-physician, the salary of 
the latter may be raised from $400 to $500 or more, but 
not sufficient to make possible the employment of another 
nurse at the same sum perhaps. It may be well to employ 
a woman physician as part-time medical examiner so she may 
better examine the high-school girls. 

The trials and tribulations of the superintendent in try- 
ing to get regular and responsible work from part-time 
physicians and in attempting to direct medical work without 
medical knowledge are now at an end. He has a small, com- 
pact, and almost entirely full-time force. These are essentials. 
The entire part-time element may yet be eliminated, but it 



ADMINISTRATION OF EDUCATIONAL HYGIENE 14I 

will mean salaries from $1,500 to $2,000, at least, for full- 
time assistant physicians. 

Later developments of the system can be made, however, 
after intelligent study and experience. If another physician 
is desired he may be obtained, and if, as the city grows, an 
assistant in physical education for the elementary schools is 
found necessary, the addition can be made. But these ad- 
ditions are intelHgent choices by an expert in educational 
hygiene, after reasonable investigation. We attempt to give 
here only minimum essentials and suggestions for beginning 
or reorganizing the work. 

At the recent International Congress on School Hygiene 
at Buffalo the writer was given practically the following facts 
by a member of a board of education of a typical New Eng- 
land city (about 9,000 pupils) with a request for a plan of 
efhcient reorganization: % 

PRESENT "INEFFICIENT" SYSTEM 

12 part-time physicians at $500 $6,000 

nurses 000 

2 truant officers 2,500 

1 elementary physical-training teacher 1,000 

I summer director of playgrounds 150 

Total $9,650 

This system, recognized by the board of education as 
inefficient and not getting results, is a finely devised machine 
for securing Httle more than a collection of pathological sta- 
tistics of school population. The time the physicians spend 
in the schools is unknown; and they have no supervision nor 
nurses to follow up cases and get treatments and cures. There 
are no pubHc dispensaries for free treatment of children, and 
a large share of the population is too poor to pay $20 for an 
adenoid operation, for example, or to provide regular daily or 
weekly treatment for favus, ringworm, discharging ears, and 
other ailments. There is enough money being spent, however, 



142 EDUCATIONAL HYGIENE 

to get efficient results in this field. Leaving the high-school 
directors of physical education in their places at the same 
salaries, we have for a beginning the following: 

PLAN OF REORGANIZATION 

1 supervisor of hygiene, a physician-physical-educator $2,500 

6 school nurses, 4 at $700, 2 at $770 4,440 

2 part-time physicians, two hours daily, at $500 1,000 

I school clinic, with dental, surgical, and medical divisions. . 1,000 

I school dentist, with stafiE of voluntary dentists 500 

New blank forms for records and reports 210 

Total $9,650 

Here we have a vastly more efficient system at the same 
expenditure of money; we have skilled leadership and super- 
vision; we have a plan which unifies all school-health agencies; 
and we have the emphasis where it belongs, on prevention 
and cures. Necessary changes can be made after adequate 
investigation by the hygiene supervisor and superintendent 
of schools. After the first year the thousand dollars of the 
budget spent for equipping the school clinic will be available 
as a salary appropriation for one or two part-time physicians. 

For the largest cities, such a health reorganization can 
easily be made, and it is practically possible for many cities 
having a population almost as small as eight or ten thousand. 
Several towns may even go together and employ such an expert, 
as superintendents are now employed in several States. And 
even rural districts may unite in the same way for the expert 
services of an educational hygienist and several nurses.^ The 
great need is for health experts and for health leadership. 
The people will respond and act along the best health lines 
when the health knowledge, now the possession of the few, 
is made the possession of the many. We have suggested here 
a possible channel for such general health enlightenment. 

* See the writer's survey of rural school hygiene in Pennsylvania as given in 
the 1914 " Rural School Report" to the Pennsylvania State Educational Asso- 
ciation. 



ADMINISTRATION OF EDUCATIONAL HYGIENE I43 

The far-reaching influence of such school-health leadership 
on national health and vitality can as yet hardly be imagined. 

Other Plans for the School Medical Service. — Disregard- 
ing as ineffective the physician-alone plan for school-medical 
work, we have two principal alternatives for serious considera- 
tion: the physician-and-nurse plan, already suggested, and 
the nurse-alone plan. For both there is the need of a super- 
vising director of hygiene, imless the superintendent of a 
small city is exceptionally well quaHfied medically and has 
time to devote to the work. We need supervisors of hygiene 
as much or more than we need supervisors of music, drawing, 
and such subjects. For both plans we may have either phys- 
ical examinations with inspection or only inspection alone. We 
shall take the stand that routine examinations, annually, are 
important as well as inspections. In the nurse-alone plan the 
routine inspections, with the use of individual cumulative 
health-record cards, can, at first, take the place of complete 
medical examinations, by simply adding the vision and hear- 
ing tests. 

The nurse-alone plan is, in general, far superior to the 
physician-alone plan, for a number of reasons, chief of which 
is that the former gets treatment and cure for a large per- 
centage of the cases, while the latter procures treatment and 
cure for but 5 or 6 to 20 per cent of the cases. Furthermore, 
the nurses can find most of the cases of all kinds, and can 
inspect satisfactorily, as proved in New York, for infectious 
diseases, especially when under supervision (September, 191 1, 
Report of Bureau of Municipal Research). Cities as small as 
Canton, Mass., with less than 5,000 population, and as large 
as Oakland, Cal., with nearly 200,000, get good work with 
only nurses, under supervision. (Reports and letters of Doctor 
Arthur T. Cabot and of Doctor N. K. Foster, respectively.) 

Newark, with thirty-eight doctors and eight nurses, has 
reversed these figures by exchanging two doctors for each 
added nurse. Only five or six doctors were kept as dis- 
trict supervisors of the nurses, With the general supervisor 



144 EDUCATIONAL HYGIENE 

as before, this has already greatly increased the efficiency 
for the money expended. Further, physicians can work but 
part time, while nurses devote their entire time to the work. 
The physicians are irregular and difficult to control in large 
numbers, while nurses, with practically no serious competing 
interests, are easily directed. And, finally, they are less than 
half, and frequently only one-fifth, as costly, hour for hour, and 
for the year, as physicians. The tables given in the writer's 
volume previously mentioned show even greater dispropor- 
tions of cost in a number of cities, when the annual number of 
daily visits, and number of hours each, are taken into con- 
sideration. Good, regular physicians, furthermore, can spare 
little more than two hours a day regularly and punctually 
from their practise; and physicians for longer periods must be 
paid too much and cannot well stand the strain and monotony 
of long-continued examination or inspection. Diminishing 
returns, with the larger salaries for full-time physicians, bring 
in the school nurse often much more efficient hour for hour 
than such physicians as can be obtained. That the nurses 
need training, before and while in service, and that they 
must have competent supervision, is immediately apparent. 
The plan here outlined, however, places the emphasis upon 
the nurse and the physician, the physician-nurse plan. Get- 
ting full-time work from all school-health officials, a great 
desideratum, remains a nice problem for careful study and 
local adjustment. The first thing is to get the hygiene super- 
visor, next the nurses, and, finally, part or full time physicians. 
A very small city unable to obtain, with others even, a super- 
visor should start if possible with a nurse rather than with 
part-time physicians. If only a physician is employed the 
principal and teachers must do the follow-up work. In either 
case the record and report forms given in a later chapter 
may be used. 

Where to Obtain School Nurses. — ^As with all other 
forms of public service, the success of medical and health 
work depends very largely upon the character of the persons 



ADMINISTRATION OF EDUCATIONAL HYGIENE 1 45 

chosen to carry it on. The greatest weakness of our school 
systems at the present time is due to the fact that our teachers 
are quite generally young women novices with a teaching 
tenure of three to five years only, and very largely ignorant 
of, and inexperienced in, the real life of the community and 
nation about them. Educational readjustment must wait 
upon the improvement of the character of the teaching force. 
With even the best of supervision and the most scientific 
plans of management the health service, likewise, can remain 
palsied, feeble, and inefficient. 

After deciding to obtain officials for the school-health 
work, therefore, the practical problem becomes one of ob- 
taining high-class health agents. For nurses, we must as 
yet depend very largely upon the various training schools 
for visiting nurses, and the visiting nurses' associations. 
The Department of Nursing and Health, under the direction 
of Miss M. A. Nutting, R.N., at Teachers College, Columbia 
University, in New York City, is at present the only insti- 
tution in the country which gives special instruction and 
training for school nurses, and the number who can be sup- 
pHed is at present very small. This is the first source I should 
recommend. 

Miss E. P. Crandall, R.N., Executive Secretary of the 
National Organization for Public Health Nursing, 52 East 
Thirty-fourth Street, New York City, and Miss E. L. Foley, 
R.N., Superintendent of the Visiting Nurse Association, 104 
South Michigan Avenue, Chicago, may also be depended 
upon to advise school systems of graduate nurses who are 
specially quahfied for and looking toward public-school work. 
Miss Fannie F. Clement, 713 Union Trust Building, Wash- 
ington, D. C, can give valuable information regarding the 
Red Cross Rural Nursing Service and persons available as 
school nurses. The Boston District Nurses Association in 
affiliation with the Boston School for Social Workers, as well 
as the Cleveland Visiting Nurses Association in affiliation 
with Western Reserve University, and, finally, Phipps In- 



146 EDUCATIONAL HYGIENE 

stitute of Philadelphia are also in touch with most nurses in 
the country. 

The editor will be pleased to send the names of any 
persons known to be qualified either as hygiene supervisors 
or as school nurses to responsible persons, without charge to 
either party. Like Albany, N. Y., a city may find in its midst 
a man qualified both as a physician and a physical educator 
for such work, and good nurses amenable to training in the 
school service. 

The Future. — ^It is not to be expected, of course, that this 
plan is a cure-all. It is based on the actual conditions and 
needs of schools and does not represent anything impossible 
in the way of money. In this country and abroad cities and 
states are actually adopting it with sHght variations, and 
we believe it is scientific and along the right lines for the best 
future growth. The recommendation of a skilled supervisor of 
hygiene in each school system or group of schools is the best 
guarantee of study, growth, adaptation, and improvement. 

The plan as extended to medical supervision I give in a 
later chapter. The State's responsibility and opportum'ty 
for school health administration and extension will next be 
taken up. 



CHAPTER IX 

A PLAN OF STATE CO-OPERATION FOR SCHOOL- 
HEALTH PROGRESS 

Importance of Co-operation in School-Health Adminis- 
tration. — The co-operative commonwealth has been the dream 
of many a philosophical imagination. No one dream has 
ever come true in detail. But that co-operation is a funda- 
mental necessity in community hfe is becoming more and 
more evident with the increasing variety ai^d complexity of 
human relations. This co-operation is desirable and neces- 
sary not only to conduct successfully business, social, and 
poHtical affairs, but it is yet more necessary to ward off and 
to correct the ills of the community, both the present ills and 
those that threaten. 

Differing points of view on matters of vital importance, 
due in the main to differing habits of thought and of action 
and to unequal distribution of knowledge, are largely respon- 
sible for those conditions in community life that are dangerous. 
An extremely unequal distribution of wealth is harmful and 
often dangerous; but the condition of ignorance regarding 
the fundamental facts that may be known in matters per- 
taining to health and industry creates situations that menace 
community prosperity. For from such ignorance result un- 
hygienic and wasteful habits of life and serious, antagonistic 
prejudices. 

Education and Health. — Education, i. e., the process of in- 
forming and training in right practises, appears to be the sole 
force by which those community conditions that menace 
health and prosperity may be bettered. In the evolution of 

147 



148 EDUCATIONAL HYGIENE 

the general educational programme every important commu- 
nity activity is involved, and it requires for its carrying out the 
employment of national and State as well as local agencies 
and resources. Particularly is this true of education in hygiene. 

Responsibility of State Departments of Education for 
Public Health. — It is not the purpose of this chapter to dis- 
cuss national and State legislation and administration of 
health agencies, but to call attention to the fact that a State 
department of education must accept in any general educa- 
tional programme a larger responsibihty than it has assumed 
in the past, viz., the responsibility for systematically promot- 
ing educational propaganda among the adult, non-school- 
attending part of the population. With this responsibility 
it must also assume the task of securing general approval 
and support in the State for those educational measures that 
it is desirable to introduce into the schools. 

Lectures and widely circulated printed bulletins have been 
the principal means employed by the State in the past for 
disseminating information. More recently specific training 
has been offered by the State in a desultory sort of way to 
adult citizens, in agriculture and other industries. But the 
numerous voluntary organizations now found in every State 
may become powerful alhes in any proper educational move- 
ment. 

The State's Share of Responsibility. — Some part the 
State must take in the affairs of each community, but in a 
democracy it would appear: 

First. — That the State should take over completely only 
those responsibiHties that by their nature cannot be shared 
successfully with local authorities. 

Second. — That it should become a partner in those re- 
sponsibiHties only which by their nature are partly extra- 
local. 

Third. — That it should not regulate any local activities 
except those upon which the prosperity of the State depends, 
and these only when local regulation has proved ineffective. 



STATE CO-OPERATION 149 

Fourth. — That so far as possible the State should express 
itself by the avenues of advice, inspiration, and information 
rather than by dictation and compulsion. 

The individuahty of a locahty must be preserved, its in- 
telligence must be promoted, its initiative must be strength- 
ened, its conscience must be kept alive, its citizenship must 
be trained, because the ''locality" is the training-ground for 
whatever citizenship is in the State. 

If the State is to succeed by democratic rather than by 
autocratic means, its measures and proposals must have the 
approval of ''public sentiment." To secure this approval 
and to transform it from a passive to an active force, it would 
appear that the State must be in close co-operative relation 
with those factors in the State that are intelligent and pow- 
erful enough to create a favorable "public^ sentiment" and 
aggressively to support a given policy in each locality. 

Getting Health Agencies to Work Together for a Common 
Purpose. — These considerations were forced upon our atten- 
tion when the commissioner of education decided to formu- 
late a comprehensive plan of instruction and training in hygiene 
for the schools of New Jersey. It was evident that any such 
plan to be effective in the schools must comprehend the 
adult population, also, since knowledge, conviction, and prac- 
tise in matters pertaining to hygiene were lacking in many 
localities. Moreover, inasmuch as the plan of school in- 
struction was based on the idea that instruction was to find 
an immediate application not only in the school life but also 
in the home and community life, there was danger that passive 
popular indifference might become active antagonism unless 
the community became partners in carrying out the plan. 

A tabulation of the agencies in the State whose co-opera- 
tion the department of public instruction might secure 
showed the following: 



150 EDUCATIONAL HYGIENE 

AGENCIES AVAILABLE IN THE STATE FOR PURPOSES OF 
EDUCATION IN HYGIENE 

I. State Agencies for Education 

1. State Board of Education. 

2. Department of Public Instruction. 

Commissioner of Education. 
Assistant Commissioners. 
State Inspector of School Buildings. 
County Superintendents. 

3. State Normal Schools. 

4. State Summer Schools. 

5. Extension Normal-School Courses. 

II. Local School Agencies 

1. Boards of Education. 

2. City Superintendents. 

3. School Supervisors and Principals. 

4. Directors of Physical Education. 

5. Teachers. 

6. School Medical Inspectors and Nurses. 

in. Agencies in the State Interested in the Provision 

OF Health 

1. State Board of Health. 

Lecturer on Hygiene. 
Lecturer on Tuberculosis. 

2. State Medical Society. 

3. State Sanitary Association. 

4. State Dental Association. 

5. State Board of Architects. 

6. Commissioners of Charities and Correction. 

7. State Grange. 

8. Local Boards of Health. 

9. New Jersey Congress of Mothers. 

10. Woman's Christian Temperance Union. 

11. New Jersey State Federation of Women's Clubs. 

12. New Jersey Sons of Temperance. 

13. United Friends' Order of American Mechanics. 

14. Patriotic Order Sons of America. 

15. Local Playground Associations. 



STATE CO-OPERATION 151 

16. Local Civic Organizations. 

17. State Agricultural Experiment Station. 

18. Princeton University — Department of Hygiene. 

19. Rutgers College — Department of Education. 

More than half of these agencies have assisted in working 
out the details of the plan of educational hygiene for the 
schools. These agencies are influential in the State as a whole 
and their members are scattered throughout the State. 

It has, therefore, already been practically proved that 
the State has a most valuable asset in its civic organizations, 
an asset that should not be ignored in any programme of 
education involving interests which they and the State edu- 
cational authorities have in common. 

Health Education of Adults. — But the general plan of 
education in hygiene will be only partially carried out when 
the programme of work for the schools haS been completed 
and distributed, and is operative in the schools with the 
general approval of the local communities. As before sug- 
gested, the time has come for the State department of edu- 
cation to assume responsibilities for the systematic education 
of those not connected with the schools, who cannot be 
reached directly through them. The theory that the habits 
of thought and conduct of adults cannot be affected by edu- 
cation is not sound. Opportunities are being offered to adults 
in many States to learn more about their own trade, or to 
learn a new one. These vocational school courses are super- 
vised and wholly or in part financed by the State. 

There would seem to be no escape from the conclusion 
that, inasmuch as health is more fundamental than industry, 
the State must assume responsibihty for the maintenance of 
the public health on as high a plane as it can be maintained. 
It is not enough to have officers going about enforcing pure- 
food laws and laws for the protection of water sources. The 
rapidly accumulating body of knowledge regarding matters 
of health in all its phases must be brought to the people in 
such a way that they will become intelligent partners with 



152 EDUCATIONAL HYGIENE 

the State in maintaining their own health and improving it 
on their own initiative. 

This hygienic intelligence, hygienic conscience, and hy- 
gienic practise can be promoted only by the process of edu- 
cation; a process of education that is operative not only in 
the schools, but continuously and systematically among the 
adults who do not attend school. 

The responsibihty for the formulation and carrying out of 
this twofold or two-sided plan of education in hygiene can 
rest nowhere but in a State department of public education. 

State Supervisor of Educational Hygiene. — To carry out 
any such plan there should be a State supervisor of educational 
hygiene. This supervisor should have had training and ex- 
perience as a physician and as a teacher. He should be com- 
petent in the fields of medical supervision, school sanitation, 
physical education, the teaching of hygiene, and the hygiene 
of methods of instruction. He should also be a student of 
sociology, and should be able to stimulate, guide, and help 
make efhcient all phases of school hygiene and the general 
education in hygiene. In brief, the health of the State is so 
fundamentally important that the maintenance of it must be 
assumed by the State. Education in matters of health is 
the only means of making hygienic practises prevail in 
the Hfe of each citizen. This education must affect the Hfe 
of the adult as well as of the young citizen in school. Any 
general programme of education in hygiene will require in 
its formulation and for its effective working the co-operation 
of other State departments interested in matters of health 
and of all available civic forces focussed in organizations 
throughout the State. The bigness and the importance of 
the problem require that its solution be placed in the hands 
of a supervisor of educational hygiene. One of the prime 
functions of such a supervisor is to secure this active, guided 
co-operation to the end that hygienic intelKgence, convic- 
tion, and practises may be promoted in every community in 
the State. 



CHAPTER X 
RURAL SCHOOL-HEALTH ADMINISTRATION 

The Rural Health Problem.^ — Health is the greatest asset 
in life. Upon it human welfare depends. Not only is health 
a condition essential to happiness, but it is also of the highest 
economic importance. Hygiene and sanitation are important 
phases of sociology, economics, and civics, because whatever 
affects the welfare of the people affects the welfare of the 
whole State. Almost one-half of the people of our nation 
live in rural communities, and the welfare of these people 
should be considered a vastly important function of the 
government, because they are engaged largely in the produc- 
tion of the materials which, either raw or manufactured, are 
the essentials of national life and progress. The more efficient 
these people are in every respect, the greater the production. 
Ill health and physical defects on the part of those who pro- 
duce these materials are not only a loss to the State but a 
menace to the health of those who use them. The sanitation 
and health of rural communities are therefore subjects of 
direct vital importance not only to the rural dwellers them- 
selves but to all. 

Health and sanitation being vital factors to the welfare 
of the people, it is a paramount duty of the State to make a 
study of these problems to the end that reliable information 
may be obtained and made available to the people. It is 
furthermore a paramount duty of the State to exercise super- 
vision over health conditions in order that the causes for dis- 
ease, physical defects, and ill health may be removed as far 
as it is possible. Especially should the State make its schools 

* See also the chapter on " Rural School Sanitation." 

153 



154 EDUCATIONAL HYGIENE 

a common medium for the dissemination of this information; 
and in order to render this instruction as effective as possible 
the school itself should be a model hygienically. The State 
already considers the training of its citizens academically a 
paramount duty and compels attendance at school. With 
such compulsion there ought also to be a provision whereby 
the State can guarantee a safe and sanitary environment for 
the young people while they attend. The schools are the 
homes of the children for a large portion of their early years, 
and to live in sanitary surroundings during those years 
means the inculcation of a definite sanitary sense which ulti- 
mately determines the hygienic standard of the home. 

Improvement of Health Largely a Matter of Education. — 
To conserve, to develop, and to enrich human life physically, 
intellectually, and spiritually, in order that man may reach 
the highest development of which he is capable, should be the 
great purpose of education. Hygiene and sanitation are de- 
partments of education of vital importance to the welfare 
and happiness of all. A consideration of what has been done 
to improve health conditions in rural schools will serve as a 
basis for considering what can be done in the future. Among 
the educational agencies which have been instrumental in 
the betterment of rural schools may be mentioned: 

(i) School-Board Conventions. — In several States large 
meetings of school ofhcers have been held for a number of 
years. In some States these meetings are provided for by 
law and the officers are paid a per-diem and mileage for at- 
tending, while in other States the meetings are volxmtary 
associations or are held in connection with teachers' in- 
stitutes. A member of the State department of education 
and the county superintendent are generally in attendance, 
and thus are afforded excellent opportunities for the depart- 
ment to learn the conditions and needs of the schools and 
the people. In Wisconsin the statutes give the teachers the 
right to attend these conventions without loss of pay or time. 
Phases of school sanitation always come up for discussion 



RIIELA.L SCHOOL-HEALTH ADMINISTRATION 1 55 

and much has been done, not only to create better school 
sentiment, but also to spread information regarding methods 
of managing schools and caring for the health of the chil- 
dren and the community. 

(2) Teachers^ Meetings, — ^Institutes of various kinds are 
held in most States and at such gatherings matters pertaining 
to hygiene and sanitation are frequently taken up. All States 
provide by law that physiology and hygiene, with special 
reference to the efifects of stimulants and narcotics, shall be 
taught in the public schools, and this naturally leads to other 
health topics. Some of the States have, by recent enact- 
ment, provided for teaching prevention of accidents. In 
Michigan the following law was enacted in 1909: 

Section i. There shall be taught in every 3^ar in every public 
school in Michigan the principal modes by which each of the danger- 
ous communicable diseases is spread and the best methods for the 
restriction and prevention of each such disease. Such instruction 
shall be given by the aid of text-books on physiology, supplemented 
by oral and blackboard instruction. From and after July ist, nine- 
teen hundred ten, no text-book on physiology shall be adopted for use 
in the public schools of this State, unless it ^all give at least one- 
eighth of its space to the causes and prevention of dangerous com- 
municable diseases. Text-books used in giving the foregoing instruc- 
tion shall, before being adopted for use in the public schools, have that 
portion given to the instruction in communicable diseases approved 
by the State Board of Health to the State Board of Education. 

(3) Farmers^ Institutes, Community Gatherings, and Rural 
Organizations of Various Kinds, — ^AU these agencies are edu- 
cational and incidentally do much to disseminate knowledge 
concerning hygiene. Bovine tuberculosis with the possibil- 
ity of its transmission to human beings has been discussed 
quite generally and with much vigor at farmers' institutes. 
Home sanitation is a subject for earnest discussion in local 
farmers' clubs. The Grange and other rural organizations 
have been and are always active in spreading information 
that will better rural conditions. The social-centre move- 



156 EDUCATIONAL HYGIENE 

ment that has for its object the general use of the schoolhouse 
for community gatherings is gaining strength and the depart- 
ments of education in various States are helping by means of 
bulletins and circulars containing helpful suggestions. 

(4) The School. — The rural school itself, humble though 
it may be, is becoming a great agency for influencing the com- 
munity in the many phases of rural Hfe. It is true that the 
teaching of hygiene, Hke the teaching of other branches, has 
not been productive of the best possible results, but the re- 
sults obtained demonstrate that the rural school can be 
made a potent factor in improving conditions. In some local- 
ities good health habits have been inculcated in children by 
giving school credit for personal care at home, as outlined in 
a pamphlet pubHshed by ex-State Superintendent E. L. 
Alderman, of Oregon. The same home-credit plan where 
tried has been found to exert a strong influence in estabhshing 
a proper attitude toward matters of health on the part of the 
child and sometimes on the part of the older members of the 
family. One county superintendent during the past year, 
through his teachers, school officers, and the school-children, 
made a campaign on the house-fly; another on the care of the 
teeth; and, through the efforts of another superintendent, all 
of the school outbuildings of a county were placed in proper 
condition and kept so throughout the year. Occasionally we 
find superintendents and teachers taking up specific problems 
of sanitation with excellent results; and these superintendents 
and teachers tell other superintendents and teachers what 
has been accomplished and they are often stimulated to try 
the same things. Can any one doubt the far-reaching results 
of such sanitary instruction? 

The teaching of physiology and hygiene in the country 
schools is continually improving: first, because more adequate 
provisions are made every year for training the teachers; 
second, better and saner text-books are available; and, third, 
the courses of study call for simple and practical instruction. 

(5) Literature on Hygiene. — ^In addition to the regular 



RURAL SCHOOL-HEALTH ADMINISTRATION 1 57 

text-books there are many excellent supplementary books, 
bulletins, and magazine articles dealing with health and 
sanitary suggestions in a popular way. The libraries con- 
tain many excellent books for home reading. In some of the 
States travelHng libraries are sent through the rural com- 
munities and these often contain popular works on hygiene. 
Many of the State boards of health publish and disseminate 
excellent bulletins dealing with various phases of health. 
Public Health, published by the Michigan State Board, is 
especially excellent. Tracts, leaflets, and circulars dealing 
with contagious diseases, the hygiene of children, and other 
matters pertaining to the welfare of the public are published 
and distributed according to the needs of each particular 
State, so far as the funds will permit. Unfortunately, in many 
of the States health departments are not given the financial 
support that they should have.^ * 

It is also true that the general press of the country is 
more than ever interesting itself in discussing hygiene and 
public sanitation. Not only is more newspaper space given 
to the subject than formerly, but the articles are far better in 
quality. Though much of the material written on educa- 
tional and hygienic subjects is not high-class and wholly re- 
liable, the better magazines and periodicals are securing the 
services of the most eminent medical practitioners and 
authorities giving information of the highest value. 

(6) Training-Schools for Teachers. — Much more attention 
is given now than formerly to the preparation of teachers for 
rural school work. Though much of this work is yet in a 
somewhat crude state, yet some success has been achieved in 
giving to these young teachers some knowledge of the subject- 
matter, some method, and some definite preparation. A 
number of the normal schools have introduced special courses 
for rural school-teachers, and training courses are being ad- 
ministered in connection with high schools. In Wisconsin, 

^ The New York State Board of Health is publishing a health almanac 
similar to those of Kansas and Virginia. 



158 EDUCATIONAL HYGIENE 

county training-schools with two-year courses for rural school- 
teachers have been estabHshed. In these special schools much 
attention is given to instruction in hygiene, physical educa- 
tion, and school sanitation. 

(7) The State Boards of Health. — Reference has already 
been made to the literature sent out by these boards. Be- 
sides circulating literature, they also do much in educating 
people directly. Members of boards of health sometimes ad- 
dress teachers' institutes, school officers' meetings, and other 
gatherings. Through their regular work of inspection they 
and the local boards do much to impress upon the people the 
importance of sanitary surroimdings. In many of the States 
the rules of the State board of health have the force and 
effect of law and many reforms have been brought about, 
such as the abolition of the common drinking-cup. 

(8) The State Department of Public Instruction and the 
County Superintendents. — ^As far as time and means permit, 
these educational forces endeavor to secure better sanitary 
conditions in the school surroundings and profitable school 
instruction in hygiene. Their responsibility is direct and 
great. 

Improvements that Have Been Made in the Sanitation 
of Rural Schools. — It is impossible in a short article to go 
into all the details of improvement in the various States and 
to give statistical information as to what has or has not 
been done. It is rather our purpose here to tell of some of 
the things that have been done administratively by the 
various agencies mentioned in order that we may be guided 
in further efforts. 

(i) School Buildings. — ^In some of the States provision 
has been made by law for the condemnation of insanitary 
school buildings. In Wisconsin this power is given to the 
inspectors in the department of pubHc instruction, who are 
delegated by the State superintendent to inspect school 
buildings when applications come to him for such inspections. 
In the capacity of State rural-school inspector it has been my 



RURAL SCHOOL-HEALTH ADMINISTRATION 1 59 

pleasant duty since the law was enacted in 1909 to put out of 
existence more than eighty health-destroying school buildings. 
The other inspectors in the department have also had their 
share in the good work, so that we now have inspected and 
removed, or improved, over three hundred buildings. The 
inspectors are empowered to order a new building, or the old 
one repaired. 

In North Dakota the county board of health, of which 
the county superintendent of schools is a member ex officio, 
has the power to condemn school buildings, and insanitary 
school buildings are often ordered discontinued. 

Several of the States have made provision by law for 
the approval of schoolhouse plans by some authority. In 
certain cases plans are provided by the State and sent to any 
district desiring to use them. In this way gi^at changes have 
been made in rural-school architecture and in rural-school 
conveniences during the last decade. Some State depart- 
ments of education issue bulletins containing suggestions for 
remodelling old schools. In numerous instances county 
superintendents have done excellent work in bringing about 
improved conditions and there are localities where many new, 
sanitary, up-to-date rural school buildings are found; and, 
as a rule, when one such building has been erected several 
others are built in neighboring districts shortly after. Good 
things are contagious as well as disease. 

(2) Sanitation of School Buildings. — The progress that 
has been made in school sanitation is usually due to one of 
two factors: (a) the educational work that has been done 
among the people themselves because of suggestions gathered 
at school-board conventions, teachers' meetings, community 
gatherings, etc.; (6) the State laws that have been passed 
regulating sanitary conditions, and the proper administration 
of such laws. Regarding the first agency, Superintendent 
J. A. Churchill, of Oregon, writes: 

The county superintendents in a large number of counties have 
taken up the matter of better sanitary conditions by calling parents* 



l6o EDUCATIONAL HYGIENE 

meetings, especially in the rural districts, and making an appeal to 
the people. As a result of these meetings we have counties in which 
every rural school building has the windows arranged so that the 
light comes from the left, where a special system of ventilation is pro- 
vided or the windows arranged with window-boards, and where the 
outbuildings are in absolutely sanitary condition. This work has 
been accomplished through an appeal to the people rather than by 
compulsion. The State board of health has helped us a great deal in 
this work by sending lecturers. 

In some States, notably Pennsylvania and Indiana, the 
law provides specifically for the proper sanitary condition of 
all school buildings. In Indiana regulations have been drawn 
up in the law for school sites, school buildings, lighting 
and seating, blackboards and cloak-rooms, water supply and 
drinking arrangements, heating and ventilation, water- 
closets and outhouses. A penalty is attached to this law, 
which reads as follows:^ 

Any agent, person, firm or corporation, selling, trading or giving 
to any township trustee, school trustee or board of school commis- 
sioners, any materials, supplies, sanitary apparatus or systems, which 
when constructed or remodelled or installed, in or for any school house, 
hereafter constructed or remodelled, which do not in all respects 
comply with the provisions of this act, shall be guilty of a misde- 
meanor, and upon conviction thereof, shall be fined in any sum not 
more than five hundred ($500.00) dollars, to which may be added im- 
prisonment in the county jail for any determinate period not more 
than six (6) months and shall be punished by a further fine of not less 
than five ($5.00) dollars for each day he shall fail to comply with any 
order of any court having jurisdiction for the correction of any such 
defects in such school houses hereafter constructed or remodelled; 
and any money claim for the construction or remodelling, or for any 
materials, supplies, sanitary apparatus or systems furnished or con- 
structed in or for any school house hereafter constructed or remodelled, 
which does not in every way and in all respects comply with the re- 
quirements of this act, shall be null and void. 

(3) Cleanliness. — In many sections where school senti- 
ment has been low, cleanHness especially has been at a dis- 

^ See the buUetia of the U. S. Bureau of Education on " Sanitary School- 
houses." 



RURAL SCHOOL-HEALTH ADMINISTRATION l6l 

count. Ill some States laws have been enacted providing 
for the cleaning of the schoolhouses. Where such laws have 
been passed, where school ofhcers' meetings are being held, and 
where the county superintendent has the energy and ability 
to do things, we find some excellent conditions. There are 
localities where most of the school buildings are thoroughly 
cleaned once a month. At least one State requires, by a 
vigorous statute, the use of something to keep down the 
dust in the daily sweeping of all public buildings, including 
schools. Lest we become too optimistic in this matter, how- 
ever, let us remember that there are still thousands of rural 
schoolhouses that do not get more than an annual soap-and- 
water cleaning; but such are rapidly disappearing. 

Maine has on its statute-books a law dealing with the 
cleanliness of the children themselves. Several other States 
have similar laws dealing with contagious diseases. The 
Maine law reads as follow^: 

When a teacher becomes aware or suspects that any of the pupils 
attending his school are in a condition which renders them a source 
of offense or danger to the other pupils in school on account of filthi- 
ness, or because they are the bearers of vermin or parasites, or have 
an infection or contagious disease of the skin, mouth or eyes, he shall 
notify the superintendent of schools, and when a superintendent of 
schools knows or learns that any of the pupils attending any school 
within his jurisdiction, are affected with any of the conditions, infec- 
tions, or diseases herein mentioned, he shall notify the parents to 
cleanse the clothing and the bodies of the children and to furnish 
them with the required home or medical treatment, for the relief of 
their trouble, and the superintendent of schools may, when he deems 
it necessary, exclude such children from the schools temporarily or 
until they may be cured, cleansed and disinfected. 

Parents thus notified of the condition of their children shall forth- 
with have them and their clothing cleansed and shall promptly do 
what is necessary, or furnish them such medical treatment as may be 
required to rid the children of vermin, parasites, or contagion; and any 
parent who fails to do what is required so that the children may re- 
turn to school with as little loss of time as is possible, shall be guilty 
of a misdemeanor and shall be liable to a fine not to exceed five dol- 
lars for the first offense, and not to exceed ten dollars for a second or 
subsequent offense. 



i62 educatio:nal hygiene 

(4) Seating. — In this matter, as in everything else con- 
nected with the country school, progress depends upon en- 
lightenment. Where the most educational work has been 
done we find the best conditions. There are country schools 
in which no one could sell any kind of desk except the best. 
In some locaHties the people have no knowledge of what is 
the best and frequently do not care. It is a peculiar fact 
that some of the worst conditions are often found in communi- 
ties where the material progress is the greatest, and some of 
the worst schoolhouses I have seen have often been those in 
wealthy communities. 

(5) Medical Inspection. — Some progress has been made in 
the matter of medical inspection in rural schools. In New 
Jersey provision is made for the medical inspection of pupils 
in all schools. The law was enacted in 1903 and is quite com- 
plete in its details. 

Massachusetts enacted a law in 1906 which makes the 
following provisions: 

The school committee of every city and town, in the commonwealth 
shall appoint one or more school physicians, shall assign one to each 
public school within its city or town, and shall provide them with the 
proper facilities for the performance of their duties as prescribed in 
this act. Every school physician shall make a prompt examination 
and diagnosis of all children referred to him, . . . and such further 
examination of teachers, janitors, and school buildings as in his 
opinion the protection of the health of the pupils may require. . . . 
The school committee . . . shall cause every child in the public 
schools to be separately and carefully tested and examined at least 
once every school year to ascertain whether he is suffering from de- 
fective sight or hearing or from any other disability or defect tending 
to prevent his receiving the full benefit of his school work or requiring 
a modification of the school work in order to prevent injury to the 
child or to secure the best educational results. The tests of sight and 
hearing shall be made by teachers. 

The State board of health prescribes the directions for 
these tests and furnishes cards, blanks, record books, etc. A 
booklet has been issued containing suggestions to teachers and 
.^.chool pnysicians. 



RURAL SCHOOL-HEALTH ADMINISTRATION 1 63 

From the report of the Massachusetts State Board of 
Education we find that this law is well enforced in some places, 
but in regard to enforcement elsewhere the following state- 
ments are made: 

In a considerable number of towns no general medical examina- 
tion of all the children has ever been made. Undoubtedly this general 
examination is far more important to the school and to the community 
than the special and casual ones. It reveals defects which have be- 
come chronic and which will permanently and vitally affect the wel- 
fare of the children. The responsibility for this examination rests 
directly upon the school committee and not upon the school physician, 
unless it is specifically included in his contract. 

The report shows that where the law is fulfilled excel- 
lent hygienic conditions prevail, while in some communities 
''medical inspection is practically a nominal affair" and "there 
is no medical inspection worthy of the name." 

In Connecticut the law provides that the school board 
^'may appoint one or more school physicians and assign one 
to any public school . . . and shall provide such school 
physicians, when so appointed, with proper facilities for the 
performance of their duties." The law is quite explicit as 
to what shall be done in case physicians are appointed. 

The State board of health in its biennial report for 1911-12 
makes the following recommendations: 

We have had a law on the statute books for some time permitting 
school boards to employ medical inspectors. This ought now to be 
amended so as to make medical inspection of schools obligatory. 
Some may think it a foolish expenditure of money for which the citi- 
zen should not be taxed, but such objections will not bear scrutiny. 
The authority which has the right to compel attendance at school 
has the added duty of seeing that no harm comes to those going there, 
and humanity requires that medical assistance be given children who 
may suffer through the ignorance or neglect of their parents. 

With the lengthening of the school term and the increase in the 
years of schooling demanded, there has come an advance in the work 
required. When the standards were low the work was not beyond 
the capacity of the weaker children, but with fuller courses and higher 
standards this has changed, and inquiries must be made regarding the 



164 EDUCATIONAL HYGIENE 

children who do not keep up with their classes, in order to diminish 
the present economic waste from misdirected educational efforts. 

These objects can only be obtained by a system of routine inspec- 
tion of the children by medical men interested not only in public 
health but also in education. 

In New York the legislature enacted a law in 19 13 re- 
quiring medical inspection in all public schools. The act 
also provides for the appointment of a State medical in- 
spector of schools, by the State commissioner of education. 
The department of education has therefore a real depart- 
ment of school hygiene. 

The Pennsylvania law also provides for medical inspec- 
tion of all schools, but it has a provision to the effect that 
school districts of the fourth class (which would include rural 
districts) may decide by vote not to have inspection, and the 
medical inspection does not come under the jurisdiction of 
the State department.^ 

In Minnesota, Virginia, and Michigan specialists are 
employed to visit as many schools as possible. The work 
that has been done in Minnesota is given in the bulletin, 
'' Organized Health Work in Schools," published by the United 
States Bureau of Education. 

The school law of Utah provides that the teachers of 
the State shall conduct certain physical examinations of the 
school-children. These examinations are made under rules 
prescribed by the State board of health. Provision is also 
made that the boards of education may employ regularly- 
licensed physicians to make these tests. 

The State legislature of Ohio enacted a medical-inspection 
law in 1913 which makes it optional for school boards to 
employ one or more medical inspectors. Two or more dis- 
tricts may unite in the employment of one inspector. The 
provision is made that the inspector must be a regularly 
licensed physician. 

^See the Rural School Hygiene Siirvey by the Editor in the Report on 
Rural Schools, Superintendent N. C. SchaeSer, Harrisburg, Pa. 



RURAL SCHOOL-HEALTH ADMINISTRATION 1 65 

(6) School Outbuildings. — The toilet facilities in many 
country schools are inadequate and this results in insanitary 
conditions. School officers' meetings, the training given to 
teachers for rural schools, and the enactment of statutes pro- 
viding specific standards for outbuildings, have much improved 
conditions in many localities, but in order to bring about 
proper and permanent results it is necessary to secure the co- 
operation of school officers, teachers, parents, and children. 
The improvement of conditions in these respects is of itself a 
phase of the general educational problem. ^ 

In the discussion of the above topics attention has been 
called to some of the things that have been done to improve 
health conditions in the rural schools. It has not been the 
aim to give a full account of the conditions as they actually 
exist. Such an account would have no pQ^rticular value in 
connection with this work, but from what has been done we 
can formulate some plans as to what can and ought to be 
done, and in planning the work it is well to keep in mind that 
progress involves: 

(i) A campaign to interest the people in work of hygiene 
and sanitation, thus securing their hearty co-operation; and, 

(2) The co-operation of all agencies and forces having 
part in the work, in order that the most efficient system of 
health supervision may be established as described in a 
previous chapter. 

Following are some suggestions made to improve health 
conditions in rural schools and through them general health 
conditions in rural communities. 

The State departments of education need to he strengthened 
in many cases. It should be kept in mind that the State 
superintendent is the educational director for the State. The 
campaign for better health should be made a part of the 
regular State educational propaganda, all forces and agencies 
working under the direction of, or in co-operation with, the 

* See Dresslar's bulletin on " Rural Schoolhouses and Grounds," U. S. Bureau 
of Education. 



l66 EDUCATIONAL HYGIENE 

department of education. Enforcement of law depends upon 
popular opinion and popular will, and these, in turn, depend 
upon the education of the people. 

It is encouraging to note that the State departments 
in many States have been materially strengthened of late. 
In Iowa two field workers were added by the last legislature, 
and in Wisconsin the State superintendent's ^'official family'* 
now numbers fifteen members. In Alabama the State super- 
intendent has been enabled to secure the services of two 
rural-school supervisors through an appropriation made by 
the General Education Board. In many of the other Southern 
States one or more rural school supervisors are secured through 
appropriations made by this Board. In many of the States 
there is now possible a strong organization of the educational 
work. 

With a strong staff the State superintendent can direct 
effectively a health programme in the schools. He should 
have the aid of all the educational agencies of the State; and 
the services of the State university, the normal schools, and 
all other educational institutions and forces should be at his 
disposal, so that he may feel free at any time to utilize any 
specialist that may be adapted for this work. 

With the strengthening of the State department of education 
must come also a higher conception in the minds of the people 
of the importance of the office of county, district, or local super- 
intendent of schools. This official naturally holds the key 
to the educational situation in his administrative area. The 
county superintendent's position is, however, often inade- 
quately provided for, either with funds or with office assist- 
ance. With the limited means at their command and the 
great amount of work to be done, it is, however, surprising 
that so many county superintendents find time to be the real 
educational leaders that they are. 

The State hoards of health need strengthening in many 
instances, in order that on their own initiative and in co- 
operation with the State department of education they may 



RURAL SCHOOL-HEALTH ADMINISTRATION 1 67 

issue publications of an educational, advisory, and adminis- 
trative character, and also help conduct meetings of various 
kinds. The two departments working hand in hand can 
accomplish far greater results than both working alone. 

The local hoards of health need to be improved in effi- 
ciency. In some States there are county boards of health 
or a county health officer, while in other States the local 
boards have charge of townships, villages, and cities. Fre- 
quently the local officer is a physician, hut often he is not. In 
the latter case he usually knows little about his duties and 
does not have the confidence of the people. In some States 
it would seem that conditions could be improved by raising 
the qualifications of the local health official. I have frequently 
been asked in school-board conventions questions regarding 
procedure in certain cases. When I have answered that this 
is a matter for the local health officer, I Rave received the 
reply: ^'He knows no more about the matter than we do." 
In the appointment of health officers it should be kept in 
mind also that such officials need to have tact in handling 
people as well as knowledge in handhng cases of disease, es- 
pecially when school questions are involved. 

There should be co-operation between the local educa- 
tional officers and the local health officers. The local school 
boards should be advised by the local health officers in all 
matters pertaining to health, and all orders of the health 
officers, State and local, should be enforced by the school 
officials. The plan of North Dakota to have the county 
superintendent an ex-officio member of the county board of 
health seems good. The plan, suggested by the editor of this 
volume, of having supervisors of hygiene who are physicians 
and physical educators for rural administrative areas, would 
make for remarkable rural hygiene development. 

A most commendable practice is to have also a local 
school nurse who gives all her time to the schools within her 
jurisdiction. Such an officer would be a large factor in es- 
tablishing the proper relations between the schools and the 



1 68 EDUCATIONAL HYGIENE 

homes. She would work under the direction of the local 
board of education and in co-operation with the health officer 
and county superintendent. In Wisconsin a law was enacted 
in 19 13 permitting the county board of supervisors to pro- 
vide for the employment of a visiting nurse. In Pennsyl- 
vania any board of school directors may employ one or more 
school nurses. The rural school nurse will probably come 
before the rural educational hygienist, except as the latter is 
employed by the State and very progressive counties. 

A reasonably adequate system for health or medical 
supervision in the rural schools would include the following: 

(i) A State board of health with power to make rules 
that shall have the force of law, this board to work in co- 
operation with the State department of public instruction in 
its educational propaganda; and 

(2) A State supervisor of educational hygiene, with as- 
sistants to act as State inspectors as at present. 

(3) A local board of education (preferably county) to 
guide the work in co-operation with the local boards of health, 
and school-health officers and visiting nurses to work under 
the direction of the local board, and all to execute the general 
orders issued by the State boards of health and instruction. 

A steady, sane campaign in behalf of better health is, of 
course, indispensable, and every opportunity and agency 
should be utilized to spread information and to create the 
proper civic sentiment. 

The Rural Hygiene Working Forces.— Having roughly 
sketched a plan for rural school-health supervision, we may 
next consider its working forces. 

The Teacher. — Some inspection and care must always be 
exercised by the teacher. She should know the symptoms of 
common contagious diseases and be given authority to send 
home children having these symptoms, and the cases should 
then be referred to the health officers. 

The teacher should also have some knowledge of phys- 
ical defects of children, in order that she may be able to de- 



RURAL SCHOOL-HEALTH ADMINISTRATION 1 69 

tect faults of vision, hearing, speaking, etc., and to deter- 
mine their probable causes, as well as to suggest remedies. 
Here, however, is where the great value of the school nurse 
comes in. Having special training, she can intelligently sug- 
gest to the teachers and parents what ought to be done in each 
individual case. By working with the teacher and county 
superintendent she can add immeasurably to the health and 
efficiency of the school and the community. Cases which are 
too difficult for the teacher to handle can always be taken in 
hand by the nurse. 

The teacher should also be, to a great extent, her own 
sanitary inspector. A knowledge of the laws enacted by the 
legislature or rules passed by the State board of health fixing 
certain hygienic standards for country schools should be a 
part of her attainments, and it should be the duty of the 
teacher and the school board, under th^ direction of the 
county superintendent, to see that these regulations are com- 
plied with. Any intelligent teacher can in a short time read 
one or more of the new and informing books on school and 
community health. 

The County Superintendent. — ^An inspection of sanitary 
conditions can be made by the county superintendent in con- 
nection with his visits to the schools. He should have the 
power to enforce the laws and rules of the State by being 
given the power to pass upon a district'' s right to participate in 
the apportionment of State school funds. Cases of physical 
defects coming to his attention should be reported to the 
school nurse, the medical inspector, or the parents. 

The county superintendent, being the educational leader 
of the county, should also plan and arrange for the discussion 
of hygienic topics at teachers' meetings, school-board conven- 
tions, parents' meetings, and other gatherings. He should 
also be a vital factor in training teachers and should frequently 
visit schools and classes where his future teachers are being 
educated and trained. The more closely the students can 
be made to know actual conditions, the better they can be 



lyo EDUCATIONAL HYGIENE 

trained to improve these conditions when they become teach- 
ers. 

The School Nurse. — If a school nurse is employed, she 
should become the most important factor in the health super- 
vision of the county or the community. She should make 
regular inspections of the pupils under her jurisdiction and 
keep records of their conditions. She should, without delay, 
visit and inspect localities where epidemics are reported. 
She should help the teachers and county superintendent in 
the various meetings. She should follow up cases of ill health 
or physical defects, and thus become an invaluable help to 
the parents. Many valuable suggestions will be made to the 
teachers incidentally and it is easy to see that in a short time 
the standard of efficiency for the teachers would be raised. 
The nurse should also be a vital factor in the preparation of 
teachers for their work and should therefore be an adviser of 
the faculties having in charge the training of teachers. 

The Local Health Officers and Medical Inspector. — If a 
visiting nurse is not secured, most of the work she would do 
will have to be assumed by the local health officer. In case 
a nurse has been secured, the work of the health officer will 
be largely to act in case of contagious diseases, and to have 
charge of the legal phases of the problem, such as quarantine, 
closing school, disinfection, etc. Cases would also be referred 
to him which might be beyond the power of the school nurse 
to care for. He should be the chief factor involved in send- 
ing defective children to proper institutions and the proper 
person to take the matter up with the judge who has power 
to commit individuals to such institutions. 

The State hygiene inspectors would be called upon in ex- 
traordinary cases only as far as the general administration 
of the law is concerned. They would, however, spend con- 
siderable time in the field studying conditions, in order that 
the best methods might be adopted, school and rural-life hy- 
giene promoted, and epidemics prevented. 



PART III 

THE DIVISIONS AND PRACTICE OF EDU- 
CATIONAL HYGIENE 

I. MEDICAL SUPERVISION OF SCHOOLS 

CHAPTER XI 

THE STANDARDIZATION OF THE SCHOOL MEDICAL 

SERVICE 

The Health Census of School-Children. — ^After a plan of 
administration is effected, the first problem confronting school- 
health officials is that of learning the exact health status of 
all the children in the school system. Until a health census of 
the pupils has been taken and an accurate diagnosis of pre- 
vailing ailments made, school-health agents do not know the 
problem they are to solve. Accurate knowledge of the phys- 
ical and mental natures of the children must be the basis 
of all curative, preventive, educational, and developmental 
work. For this and other reasons we set medical supervision 
first among the five divisions of school-health practice. It 
would probably be more attractive to start with play and 
playgrounds and the glorification of health and splendid phys- 
ical development, but the need of carefully examining our 
difficulties and sizing up the nature of our problem probably 
outweighs this feature. Too much of our educational work is 
now done in the dark, with little sense of just what the prob- 
lem is which confronts us. 

We need not trace the history of medical supervision. It 
started on an active, vigorous course only in the opening years 
of the twentieth century, although scattered and feeble efforts 
may be noted before. It was, in this country, an invention of 

171 



172 EDUCATIONAL HYGIENE 

Doctor Durgin, of the Boston Board of Health, devised for 
the purpose of lessening the frightful losses due to the various 
infectious diseases of childhood. Doctors visited the schools 
at intervals and either went into the classrooms to inspect 
the children for signs of infectious ailments or had teachers 
send to the office or doctor's room in the building such chil- 
dren as the teachers suspected of showing symptoms of in- 
fectious ailments. This was medical inspection, and it has 
had a wide vogue and has done much good. In many cities 
teachers have been depended on almost entirely to detect 
symptoms of ailments and to isolate the children on the 
doctor's arrival. This system is really teacher inspection 
rather than medical inspection. 

To-day an entirely new spirit has entered into school 
medical work — the spirit of preventive medicine. Instead of 
limiting itself to discovering and isolating contagious dis- 
eases, an effort is made also to discover and to correct 
physical defects and incipient ailments before irremediable 
damage is done, and to place the whole emphasis upon pre- 
vention rather than cure. Instead of a slight and passing 
inspection for the mere signs of infectious ailments, thor- 
ough periodic physical examinations of all pupils, and vigorous 
follow-up, educational, developmental, preventive, and cura- 
tive work, are carried on. No phase of preventive medicine 
offers more promise of great development and usefulness than 
school medical supervision. 

In the plan here presented the term inspection is contrasted 
with examination, and both terms are necessary; consequently 
a broader term than medical inspection is desirable. In Ger- 
many and in a number of cities in this country the term 
medical supervision has been used for this broader medical 
work. Some persons have recommended the term health 
supervision; but this is poor in that it applies to the work 
of the whole hygiene department with its five divisions. 
Since medicine is broadening^to take in prevention, although 
the latter is not yet legally a part of the work of medicine 



STANDAEDIZATION OF SCHOOL MEDICAL SERVICE 1 73 

as defined by statute-books according to Doctor Goldwater, 
there will soon be little or no objection to the term medical, 
except from the ubiquitous health fakirs. No term so well 
covers this field, it seems, as medical supervision. 

School Examinations and Adult Examinations. — The care- 
ful routine and periodic examination of individuals, with oc- 
casional less complete inspections and careful advice and pre- 
ventive work, is not confined to schools alone. Insurance 
companies have long had examinations, and lately they have 
quite vigorously entered the field of preventive medicine. If 
the saving of Hves thus effected is profitable to business cor- 
porations, how much more profitable to the state is the saving 
of its prospective citizens ! Through the efforts of The Life Ex- 
tension Institute principally, many business organizations out- 
side of the field of insurance are now taking upon themselves 
the duty of employing expert physicians to make careful phys- 
ical examinations, periodically, of all employees. Thousands 
of employees are now getting such assistance. The examina- 
tions are more thorough than those for insurance, including 
blood pressure, blood analysis, urine and other tests, and a 
most careful inquiry into habits of life, heredity, and slight 
symptoms of pathological beginnings. 

The disclosures from such examinations are remarkable 
and in many cases alarming. Doctor S. S. Goldwater, Com- 
missioner of Health of New York City, reports as follows: 
*' Eight hundred garment- trade workers were examined; 62 
per cent of those examined were found to be in need of medical 
treatment. In a similar investigation in Germany fifteen dis- 
eases or conditions of physical impairment Were found among 
every ten workers examined. In a recent examination of 
the employees of a New York City bank 100 per cent of the 
employees were found to be abnormal and on the sure road 
to diseases of heart, lungs, kidneys, or blood-vessels."^ 

Doctor Goldwater and others maintain the same position 

* See also the s5miposium by Dublin, Winslow, Fisk, and Davenport in the 
Popular Science Monthly for April, 191 5. 



174 EDUCATIONAL HYGIENE 

as that expressed by the writer on the first pages of this volume, 
namely, that preventive medicine and pubUc health agencies 
cannot do their proper work and utmost good until qualified 
physicians, educated in preventive medicine, are employed 
for the whole population, by the people, for the people; and 
that such health agents are not merely for the treatment of 
acute and advanced cases of disease, but as medical advisers 
and protectors of health, for keeping them well rather than 
getting them well. More private physicians must become 
State ofiicials if we are ever to insure the automatic discovery 
of the beginnings of disease and physical defects, and especially 
of those various degenerative diseases now increasing in this 
country. 

Such State health examination and education must be- 
gin at the beginning of life and continue through all ages. 
The work of the schools reaching, through school nurses (such 
as are already employed for adults by health departments 
and business firms), the children of pre-school age and even 
infants, are not doing something entirely unique. They are 
working along the Kne of a common development which is 
bound to take place — the sociaKzation of preventive medicine. 
In Sweden the public medical examination reaches beyond 
school life for most children, there being an actively enforced 
law requiring that each minor under eighteen years of age be 
medically examined annually, at the expense of the govern- 
ment, to determine how far the work in which the youth is 
engaged may have injured his health. If the examination 
shows that the occupation has been injurious to the youth's 
health, he is forbidden to continue, and is given simple voca- 
tional guidance of a health character. Halsey says that in 
191 1 there were 39,971 working children examined, and of 
these 501 were assigned to more hygienic work, while 81 were 
absolutely forbidden to continue work and shown how to 
build up their health. This is a fine beginning. National or 
State insurance, such as exists abroad in England, Germany, 
Austria, and elsewhere, is bringing on universal medical 



STANDARDIZATION OF SCHOOL MEDICAL SERVICE 1 75 

supervision; and the control of occupational, degenerative, 
and infectious diseases will help it along. Even now the State 
of Pennsylvania requires at least monthly expert medical 
examinations at the employers' expense of all persons working 
in the lead industries, and requires elaborate preventive 
measures in connection therewith. 

School medical supervision must, then, unite with the 
general movement of preventive medicine as its most prom- 
ising child. This whole movement in general has, accord- 
ing to Goldwater, three essential phases: 

" (i) Education, which is essential to an understanding of 
the dangers which the individual encounters. 

" (2) Regulation, to prevent environmental conditions which 
are inimical to health. 

" (3) Periodic medical examination, a necessary test of the 
value and the effectiveness of education and l)f sanitary regu- 
lation." 

These measures well describe the work of a school depart- 
ment of hygiene. As we have divided the field, medical super- 
vision of schools Hmits itself more to the study of the physical 
and mental condition of the children and the cure of patholog- 
ical and subnormal conditions. To some extent also the 
medical examiners, nurses, and workers in clinics are also 
sanitary inspectors of schools, homes, and community, and 
educators of children, parents, and pubHc. Usually school 
sanitation, inspection, and improvement and the education 
of the children will be done by other than the medical workers. 
The various phases of medical-supervision work are given 
below. ^ 

The Divisions of Medical Supervision. — The various 
phases or divisions of the work of medical supervision^ in 
this plan and, for the most part, but largely unrecognized, in 
the best systems now in vogue, are about as follows: 

»From "School Health Administration," by the writer. 
'The term will probably remain medical inspection, even if it is a mis- 
nomer in good systems. 



176 EDUCATIONAL HYGIENE 

(A) Preliminary clinic, for instruction and standardiza- 
tion. 

(B) Inspections. 

(i) Pupil inspections. 

(a) September room inspection of all pupils, by doctors 
and nurses. 

{b) Occasional room inspections of classes of children, by 
nurses. 

(c) Individual inspection, by teachers, nurses, and doctors. 

(2) Environmental inspections. 

(a) Home hygiene inspection, during home visits of nurses. 

(b) Sanitary inspections of the school premises, by any 
delegated and competent officer. 

(C) Examinations, complete physical, annually for all 
pupils. 

(i) Scholastic: vision and hearing examinations, and per- 
haps others, by the nurses. 

(2) Medical: only those technical phases which the nurses 
cannot do well, if any, by doctors. 

(3) Psychological: in special cases where mental defect- 
iveness is suspected, by psychologists. 

(4) Anthropological: measurements of height, weight, 
chest-expansion, and the like, only if required. Of doubtful 
value as usually made and followed. 

(5) Work certificate: will probably not be needed in well- 
conducted systems, since the pupil's health condition is always 
well known ; but vocational guidance may play an important 
part here. 

{D) Treatment, cure, and correction. 

(i) By home and family physicians, dentists, or oculists. 

(2) By school nurses. 

(3) By dispensaries or other free clinics. 

(4) By public-school cHnic, with various divisions. 
(£) Prevention. 

By looking for causes, co-operating with other divisions 
of educational hygiene, and other public and private health 



STANDARDIZATION OF SCHOOL MEDICAL SERVICE 1 77 

agencies, and by placing the emphasis upon preventive rather 
than merely curative agencies. 

How to carry on efficiently and economically these dif- 
ferent phases of the work will be the problem of this chapter. ^ 

{A) The Preliminary Standardization Clinic. 

In the typical city for which the reorganized expendi- 
tures were given,^ with a proportion of little over 3 per 
cent of current school expenditures for the entire depart- 
ment, including medical inspection, we have two physicians 
and three nurses for 6,000 pupils from kindergarten through 
high school, 3,000 for each physician (one, the director), and 
2,000 for each nurse. For a city of 12,000 children we should 
have, of course, twice as many nurses and three assistant 
physicians. But no matter how large or h^w small the de- 
partment may be, even one physician and one nurse, there 
should be, when they begin to work together, and, if several, 
at the beginning of each year or oftener, a meeting at which 
children are examined or inspected, or both, and standards for 
referring cases to parents, for exclusions, for readmissions, for 
test methods of doing the work, and the like, are discussed. 
Teachers and principals may be present at such meetings, 
and all may take a hand in coming to some common agree- 
ment, without which there will, in isolation, develop the 
greatest irregularity among different workers and frequent in- 
justice to children and parents through conflicting standards 
and methods. 

This is also the opportunity for the supervisor to outline 
the work of the year, and to get suggestions from all con- 
cerned as to its improvement. It is a time for inspiration 
and education. All need them. Such clinics can be held at 
one or more of the several schools, if desired, or at teachers' 
meetings, for the purpose of giving the teachers necessary 
elements of child-study of a medical character, which prob- 

*See Hoag and Terman's " Health Work in the Schools," pages 16 to 25. 
» Chapter VIIL 



178 EDUCATIONAL HYGIENE 

ably never appeared in any course in their professional prepa- 
ration. 

No city known by the writer now employs this means 
for making efhcient medical supervision, and he hopes for 
its speedy experimental testing. Besides these will come, of 
course, monthly or semimonthly department meetings, which 
are now quite common in good systems. 

(B) Inspections. — (i) Pupil Inspections, 

(a) September Classroom inspections. — Since this plan of 
administration gives the physician as many pupils as he can 
examine in the entire year, beginning in September about 
the third week, and taking pupils in the same order each 
year, we must provide what many cities have been driven 
to by hard experience, namely, a preKminary, complete, 
routine, classroom inspection of all pupils. With 3,000 
pupils, each pair of nurses and physicians will have about 
seventy-five rooms, counting 40 pupils to a room. By requir- 
ing the part-time physicians to spend three hours a day in 
this first general inspection, and with the nurses all at the 
same work, counting a classroom, after practice, for each 
half-hour, and records made, where two work together, we 
can see that the inspection of all children can be made in 
about two weeks. 

Some doctors lay claim to 250 pupils room-inspected an 
hour, but these are only very partial inspections, for signs 
of parasitic or infectious disorders. This first general routine 
inspection would make a fair substitute for an examination, 
especially if there were any careful attention given to vision 
and hearing. It is a general inspection of the child for any 
serious defects, ailments, or conditions which should receive 
early treatment and care. No vision or hearing tests, as 
such, are made, but all obvious cases, like strabismus (cross- 
eye), or inflamed eyes from eye-strain, may be recorded and 
referred with instructions. 

The principal ailments found will probably be minor 
skin ailments of a filth or infectious character, although most 



STANDARDIZATION OF SCHOOL MEDICAL SERVICE 1 79 

ailments will be represented. If there have been nurse in- 
spections during the summer, fewer cases will be found, but 
there are always sufficient numbers to warrant rigorous 
measures for nipping their spread in the bud. 

The Method of Classroom Inspections. — The central 
instrument in all medical supervision ("inspection") is the 
individual, cumulative health-record card of each pupil. On 
it is recorded the health history of the child during his school 
years, and in some cases for the years previous to his entering 
school. The development of the science of educational hy- 
giene and the practical control of health matters must very 
much depend upon such individual health histories. Scien- 
tific control of living conditions of children, or of any other 
phenomena, rests upon the basis of accurate and carefully 
selected facts. We present herewith the faces of two such 
health-record cards devised by the writer. For complete 
descriptions and standard keys the reader is referred to the 
tentative standard plan above mentioned. 

The physician should usually make this first inspection 
while the nurse records and observes the work of the physician. 
Only the more severe cases, the infectious ailments, parasitic 
ailments, and the like, should be recorded and referred or 
excluded at this time. Vision and hearing need not be tested, 
and heart and lung examinations need not be made except in 
special cases. 

Care should be taken to record and attempt to get treated 
and cured only real and severe cases. Doctors have a tend- 
ency to defeat their efforts by referring very minor and in- 
significant ailments. Better concentrate on important cases 
and succeed in getting them cured. This inspection of all 
children may be made in the rooms or in the halls outside the 
rooms. Nurses can do the work quite well when trained, 
and teachers may help with the record work by the use of 
the code given on the weekly report by numbers. Exclusions 
should be made for diphtheria, sore throat, tonsilitis, scarlet 
fever, whooping-cough, chicken-pox, measles, mumps, tra- 



i8o 



EDUCATIONAL HYGIENE 



choma, and other acute infeetious diseases, and such parasitic 
and minor infectious ailments as prove necessary. Every 
effort should be made to keep children in school, and it should 
never be necessary to close schools. Pediculosis, impetigo, 
and such ailments may be treated at home or school, and the 
children kept in school. In several cities school janitresses 
handle pediculosis cases. 

The nurse may make out the exclusion slip, which should 
be simple, dignified, and adequately instructive. If the back 
can be used for health advice, the chance should not be 
missed. The seal of the city printed on each, as is done in 
the State forms of Massachusetts and certain cities, will ap- 
peal in the right way to many parents. The following ex- 
clusion form has several advantages in the way of economy: 



EXCLUSION RECORD 

No 

Date , 191. . 

School Room 

Pupil 

Address 

Cause of Exclusion: 



Readmitted, 
School days lost. 



191 



MEDICAL SUPERVISION OF 

SCHOOLS 

Health City, New Jersey. 

Date , 191- • 

School Room Grade 

Pupil's name 

Home address '.' 

The above-named pupil is hereby or- 
dered to discontinue attendance at 
school temporarily for the following 
reasons: 



School Nurse, M.D. 
(Hand to pupil excluded.) 

[over] 



This entire form need not be more than six inches long 
and two and a half inches wide. 

On the back of, the long part, not the stub, should be 
printed these and any other directions, general advice^ ^or 
short article from city or State laws: -^ 



STANDARDIZATION OF SCHOOL MEDICAL SERVICE l8l 

The ailment mentioned on the other side of this notice is infectious 
(contagious), and liable to be transmitted, or "given,'' to other chil- 
dren. The child should receive prompt treatment by a physician or 

the school nurse, and should return to school 

191. ., for inspection by the school physician or nurse. If found free 
from infection he may then resume attendance at school. 

Every reasonable effort should be made to give each child the full 
benefit of every possible day of school attendance. 

A Duplicate Book for Doctor and Nurse. — This form, 
separable from its stub, should be printed as is a check-book, 
and, whenever desirable, as in the case of acute infectious dis- 
eases, will, with small sheets of copying carbon, give four 
forms, the original for the parent, the stub for the hygiene 
department, the carbon copy for the board of health as their 
notification, and the carbon stub for the ijurse's or doctor's 
record. The notice can be sent home in several different ways, 
depending upon circumstances. One of these exclusion books 
should be kept in each school, and for its pupils only. 

To avoid conflict of jurisdiction, the city health officer 
and the director of hygiene, or superintendent, should meet 
and agree upon a plan of co-operation for readmitting pupils 
after exclusion or illness absence. 

Reporting the Room-Inspection. — ^When the class has been 
room-inspected, the nurse will take all the cards of ailing 
pupils to the principal's office or the health-room, where they 
can be reported after the morning's work with the physician. 
In her case-book for each school she will write down the 
name, address, room, and ailment of each defective and ail- 
ing child and the date. When she sends notices home with 
the children who are ailing but not excluded and gets no 
satisfactory results in treatment within three days or a week, 
the time for a second notice, or for home visiting, has come, 
which may even end with the doctor's visit or that of an 
officer of the law. After the fist of cases has been placed in 
her book the cards can be returned to the room, where the 
teacher will give them a separate place in her file, or mark 










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OVER 





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NUMBER OF AILMENTS 


MON TUB WED T 


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CLEANLINESS NEEDED 


































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SUM TOTALS 




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Note. — Detailed directions for the use 
be found in the editor's volume on "The 
Inspection," published by Teachers College 



of the forms of this chapter may- 
Administration of School Medical 
Columbia University. 







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STANDARDIZATION OF SCHOOL MEDICAL SERVICE 187 

them with colored clips. At the end of the day the nurse 
will record all the work of inspection and the findings in the 
column for that day's work, on the weekly report form. 
This daily and weekly report will be treated under "exami- 
nations." 

(b) Occasional Room-Inspections. — Occasionally other room- 
inspections (special room-inspection is a good term) must be 
made by the nurse after the routine one in September. Very 
rarely will the doctor be needed for such work. The method 
can be that of the general inspection described, or she can 
simply pass along the aisles and inspect the children. The 
latter can have their hands on the desks, and the nurse, 
passing along from the rear, can easily note the condition of 
the hair and scalp, as well as other features. The nurses of 
Newark made an average of nearly 500 occasional classroom 
inspections each during the school year studied by the writer, 
besides about 21,000 individual inspections and over a thou- 
sand home visits each. These room-inspections are especially 
valuable in poor or foreign districts in bringing up the health 
and cleanKness standards toward those of civilized America. 
They are also valuable, as suggested, in the case of an impend- 
ing epidemic. 

(c) Individual Inspections. — Individual inspections are to 
be made principally by the nurse, but also, if necessary, by 
the physician in the one building he visits for two or more 
hours each day. Only urgent cases are to be referred either 
by nurse or teacher to the doctor. The principal classes of 
individual inspections are as follows: 

w. Pupils referred at the time of the nurse's visit, by the 
teachers. 

X. Pupils entering that school for the first time, any age. 

y. Pupils who have been out of school for any reason more 
than three days, especially excluded, or quarantined cases. 

z. Pupils brought to the attention of the nurse in the homes. 

Where principals are, or become, qualified, a large num- 
ber of the readmittance inspections may be left to them. 



1 88 EDUCATIONAL HYGIENE 

The importance of the health training of principals and 
teachers, and the books they can use in study, will be brought 
out later. A principal who hasn't such a knowledge of 
children (child-study) needs to ^' study up." He must, how- 
ever, beware of cocksureness after little study. 

The usual place for the individual inspections is at the 
health-room or the principal's office. A bell is rung indicat- 
ing the nurse's arrival. A school janitress or a good prin- 
cipal's clerk may be of great assistance in getting the chil- 
dren ready. Each child will come with his health-record 
card in a fold of clean paper, and on this paper may be 
written the teacher's reason for sending in the pupil. He 
may be suspected of some ailment, or the teacher has noticed 
that he is not getting the treatment previously recommended, 
or for many other reasons, except as punishment. The nurse 
inspects the child, and, unless he is excluded, sends him 
back to his room, with a note to the teacher about the case 
on the same folder-protector of the card. The teacher may 
clip small memoranda slips on the cards of pupils who have 
not yet obtained treatment, or put these cards in a special 
part of her file, or she may use the various colored clip- 
markers for card indexes, each color of which may be given 
a standard meaning, as before mentioned. 

The symptom chart prepared by Doctor E. B. Hoag and 
printed in his "Health Index of Children," and separately, 
or some other set of indices to school ailments, such as are 
used in Cleveland, or printed by the writer in American 
Education, or those given by Doctor Wood in his "Health 
and Education," will be of great assistance to the teachers in 
locating the children needing to be referred to doctor or nurse.^ 
Most of the present work of medical inspection is really 
teacher inspection, since most of the cases are first noticed 
by the teachers and then sent in to the doctors. With all 
this responsibility, the teachers have not been given a square 
deal in the way of health instruction in the form of lectures, 
1 See also the bulletin of the U. S. Bureau of Education, no, 524, pp, 130-13 1. 



STANDARDIZATION OF SCHOOL MEDICAL SERVICE 1 89 

clinics, teachers' meetings, or books, by which to fit them- 
selves for their serious responsibility; and their normal or 
college courses have never, in most probability, even touched 
upon such matters. "The child," to their professional train- 
ing institutions, was quite largely a disembodied mentality, 
and psychology was the only study of his nature. 

DIAGNOSTIC TABLE, OR SYMPTOM CHART 

Disorders and Their Indications 

(to be observed by teachers, nurses, and parents) 

Teeth Defects 

Decay of teeth. Offensive breath. 

Discoloration. Poor articulation. 

Crooked teeth. .Broken teeth. 

Prominent teeth. Malnutrition. 

Disorders of Nose, Throat, and Ear 

Mouth breathing. Slow mentality. 

Prominent upper teeth. Deafness. 

Loud breathing. Poor physical development. 

Nasal voice. Earache. 

Catarrh. Discharge. 

Running nose. Inattention. 

Frequent colds. Poor spelling. 

Sore throat. Watching of lips. 

Offensive breath. Slow progress. 

Cough. Headache. 

Blank expression. 

Eye Disorders and Defects 

Sore eyes of any kind. Headache. 

Sties. Peculiar postures when reading. 

Congested eyes. Holding book too near face. 

Crossed eye. Poor reading or spelling. 

Squinting. Dizziness. 

Infectious Diseases 

Pallor. Vomiting. 

Flushed face. Headache. 



I go 



EDUCATIONAL HYGIENE 



Eruptions. 
Scratching, 
Sleepiness. 
Lassitude. 



Cough. 

Running nose. 
Congested eyes. 



Nervous Disorders 



Inability to hold objects well. 
Spasmodic movements. 
Twitching of eyes, face, or any 

part of the body. 
Irritability. 
Fits. 

Bad temper. 
Fainting. 
Nail-biting. 

Undue emotion of any sort. 
Frequent requests to "go out." 



Timidity. 

Stammering. 

Cruelty. 

Perverted tastes. 

Moroseness. 

Solitary habits. 

Undue embarrassment. 

Undue activity. 

Misbehavior. 

Sex perversions. 



Nutritional and General Disturbances 



Pallor. 

Emaciation. 

Enlarged glands in neck. 

PuflSness of face or eyes. 

Shortness of breath. 

Lassitude. 

Perverted tastes (e. g., food). 

Slow mentality.. 



Peculiar or faulty postures. 

Underdevelopment. 

Excessive fat. 

Vicious personal habits. 

Low endurance power. 

Irritability. 

Disinclination to play. 

Fatigue. 



Defects of the Feet 



Walking "pigeon-toed." 
A shuffling, inelastic walk. 
Toeing markedly out. 
Advancing foot by exaggerated 

knee action. 
Long axes of foot and leg meet at 

unusually wide angles. 
Shifting from foot to foot. 
Standing on outer edge of feet. 
Locking knees. 
Leaning against wall or desk. 



Shoes run over at either side. 

Front of heel worn down. 

Outer and back part of heel worn 
down. 

Wearing out of soles asymmetric- 
ally. 

Congestion of the feet. 

Swelling, puffiness. 

Excessive perspiration. 

Callouses. 

Twitching of the foot muscles. 



STANDARDIZATION OF SCHOOL MEDICAL SERVICE 191 

Incorrect Posture 

Unequal height of shoulders. Flat chest. 

Standing on sides of feet. Curved back. 

Prominent abdomen. Stooping. 

If this chart of symptoms devised by Doctor Hoag is printed on a 
heavy card and furnished each teacher, she will be given much assist- 
ance in doing her part. See his "Health Index of School Children^' 
mentioned above. 

(2) Environmental Inspections. — ^After pupil inspections, 
according to our outline, come environmental inspections. 
Home visiting, or home hygiene inspection, by nurses is about 
their most important work, and the problem of school sanita- 
tion will soon come up in any thorough system of medical 
supervision. The home-hygiene inspections^ at the time of 
the nurse's home visits are becoming exceedingly valuable 
citizen-making institutions, and no words here can indicate 
the spirit, the possibilities, or the methods of that humane 
and scientific work. We arrange for the records of such 
visits in cipher on each individual record card. Each nurse 
should obtain Doctor Hoag's or Doctor CornelFs book, and, 
at least, a book probably now published by the first munic- 
ipal school nurse of America, Mrs. Lina Rogers Struthers, 
R.N., recently superintendent of school nurses at Toronto, 
and formerly of New York City. Doctor Dresslar's book on 
*' School Hygiene" is also a desirable volume on the whole field. 

In certain small cities the experiment has been success- 
fully tried of making the nurse the attendance officer also 
(thus saving another salary as related), so that she can go to 
a home and handle a case of truancy effectively, as any other 
school "case." The possibilities have not yet been half dis- 
covered in this whole field of home visiting. Even where 
there are attendance officers, the nurse becomes their most 
valuable assistant. 

School sanitation inspection is more naturally the work 
of the superintendent, director of hygiene, principal, and 



192 EDUCATIONAL HYGIENE 

business manager; but the nurse and the physician should 
know enough about the subject from such texts as Shaw's 
or Dresslar's books on ^'School Hygiene/' or the other books 
mentioned, to do effective work in calling to their attention 
as often as is necessary evil conditions of lighting, cleaning, 
heating, ventilating, the condition of toilets, the necessity for 
play, playgrounds, and play apparatus, sanitary drinking- 
fountains, the proper kind of dusting, and all such matters. 

The Board of Health of Philadelphia has a special card 
form for recording the facts of school sanitation, and Doctor 
Hoag has a portion of his book and a pamphlet devoted to 
a "Sanitary Survey of Schools," which is of great assistance 
to the amateur.^ Quite frequently the nurse or the school 
physician will observe unhealthful conditions not noticed by 
teachers or principals and, then, may be even more success- 
ful than they in remedying these conditions. It depends upon 
who has the ability to translate private opinion into public 
opinion and private scientific knowledge into public action. 
-(C) Examinations. 

There is no need of calling these physical examinations 
except where the word examination is (badly) used for inspec- 
tion. We have suggested that a thorough, routine room- 
inspection of children for all ailments of a serious character, 
recorded on the health-record cards, is very much Hke an ex- 
amination. It is, however, not so individual, so intensive, 
and so technically diagnostic. Inspections will frequently 
overlook decayed teeth entirely, and will never include routine 
vision or hearing tests, nor will they ever require, perhaps, the 
stripping of each child to the waist, as a matter of routine and 
without suspicion of some heart or lung ailment. An exami- 
nation should be a patient, scientific investigation of a child's 
health status, regardless of whether he is suspected of having 

^Whitaker and Ray-Wiggin Co., San Francisco, or Paul Hoeber Co., 69 
East 59th Street, New York City. See also the New Jersey form of 1 14 points 
in the U. S. Bulletin, no. 524, pp. 127-129, and the form used by Doctor Ayres 
in the Springfield (111.) School Survey, given earlier. For rural schools, Doctor 
Dresslar's government bulletin on " Rural Schoolhouses and Grounds." 



STANDARDIZATION OF SCHOOL MEDICAL SERVICE 1 93 

an ailment. Such examinations should not be painfully long 
and impractical, however, in their minutiae. Quick, accurate, 
and thorough observation and judgment can be developed in 
this field as in any other. Much will depend upon the phy- 
sician and the nurse and what they have in their minds as 
questions and problems regarding each child's health condition. 

The examinations should be made in the health, or medical, 
room. This should be about half the size of an elementary 
schoolroom (25 by 16), and be well Kghted. It should have 
both hot and cold running water, a toilet adjacent, facilities 
for a combination tub and shower bath, a couch, several 
chairs, an anteroom for those awaiting examination, filing 
cabinets for case cards (for systems needing them), a table 
or desk or two with drawers, a medicine cabinet, a white- 
enamelled iron-and-glass stand, white-enamel wash-basins, 
and the various test-cards, medicines, and the Kke needed 
by nurse and physician. Types of equipment and suppHes 
are given in a former chapter. Many schools add to these a 
platform scale, usually a "Jones," with height standard at- 
tached. Its necessity as a matter of general routine for all 
school-children is yet to be demonstrated, however. 

The Method of the Examinations. — ^As suggested, it will 
probably be best for the nurse to be present each day during 
the two hours or more of the examination, so she can confer 
with the physician over cases and help in handhng the chil- 
dren, making the vision and hearing tests, taking the records, 
etc., as can best be arranged. Scientific management in busi- 
ness does some of its best work with seemingly minor details 
of daily practise. There is great opportunity for the practise 
of its principles in medical supervision and especially in the 
examinations. This condensation of the plan, however, must 
limit itself to bare essentials, in order not to exceed all space 
limits. 

Wie have urged that the vision and hearing examinations, 
once a year or less often, as is found better, be given by the 
nurse and not by other persons; and that she do this, as 



194 EDUCATIONAL HYGIENE 

much as possible, at the time the physician of her district 
makes his two-hour daily visit to some one school. One 
nurse will work with the physician at all times, while the extra 
nurses will devote themselves to inspections and home visiting. 
Here, at the ringing of the bell which indicates the physi- 
cian's arrival, or before, children suspected of having serious 
ailments or who for some reason require immediate attention 
are sent by the teachers or nurse to the health-room. At 
the same time pupils of the lowest grades, a room at a time, 
are sent, by threes, to the health or medical (inspection) 
room. The nurse quickly inspects the serious cases, referring 
to the doctor for further inspection such as are puzzHng, and 
then disposes of the first group. If desired, they may be 
examined at this time. 

She then prepares, as may be necessary, a child (of the 
three mentioned) for the doctor's examination, calling his 
attention to any ailments or history of the child familiar 
to her and necessary for him to utiHze, and begins, herself, 
to test the vision and hearing of another child. By the time 
the doctor is through with his medical examination she will 
perhaps be through with these two tests, and all can be 
recorded on the health-record card of the pupil, exclusions 
can be made, or notices to parents regarding serious physical 
defects or other ailments signed. Each case (name of child) 
will be placed in her case-book, or on a case-card on file in 
the health-room or principal's office. Such cards for de- 
fective pupils are found necessary in many cities. The one 
used by Newark is sent to the *' department of medical in- 
spection" when the case is concluded. Cards not sent in by 
the end of the school term are used for follow-up work in 
the summer. Whenever a case is concluded, the teacher 
should be notified. The word "case" is frequently used to 
mean both a single child and all his ailments at any one 
time, and again each one of the ailments found, so that a 
child might be six or more cases at once. If the term is 
used (and it probably should not be), it should refer only to 



STANDARDIZATION OE SCHOOL MEDICAL SERVICE I95 

one child with all of his ailments, whether one or many, at 
any one time. Usually every new ailment he gets will make 
another case. Then, instead of recording the number of 
'^ cases," the number of different ailments should be given, and 
for a large group of children there will always be more ail- 
ments than pupils — ^probably, on the average, two or more 
to one. 

The time of the examination should preferably be from 
nine to eleven each day, and each day in a different school 
during a week or longer, depending upon the number of 
schools it takes to supply about three thousand children, 
and somewhat upon the locality, of course. Perhaps two 
thousand for the doctor and the same or fewer for the nurse 
may be found desirable in a poor, foreign district. For small 
schools the doctor's visits should be distributed over the year. 
A school with 200 pupils will mean about ten visits, or one 
every three or four weeks. Compromises may be made here. 

"If the nurse and doctor go to the same school, how can 
we have inspection at other schools each day? '' some one may 
ask. This is one of the reasons for the extra nurse in the 
typical city. She will do this work. Otherwise, the prin- 
cipals and teachers must use their discretion, as they have 
done for so long, until the nurse can come in the late morn- 
ing or in the afternoon. Some of these daily inspection 
visits she can avoid by telephoning to a school and finding 
whether the teachers have looked and found any urgent cases. 
On schedule, she will probably get to one or two of these 
other schools each afternoon anyway. 

We cannot go into further details with respect to the 
examinations of various kinds, psychological, scholastic, 
dental, and others. There is httle need of dentists making 
dental examinations when nurses and doctors give the neces- 
sary care to this part of the complete survey of the child. 
Directions for making vision, hearing, and mental tests may 
be found in other works. 

Whenever a referable, non-infectious ailment is found 
during inspection or examination, the following note to par- 



196 EDUCATIONAL HYGIENE 

ents may be filled out from the cards and enclosed in an en- 
velope by the nurse to be sent to the parents: 

Medical Supervision of Schools, 

Health City, N. J. 

NOTICE TO PARENTS OR GUARDIANS 

This notice does NOT exclude the pupil from school. 

Date , 191. . 

The parent or guardian of 

is hereby informed that a physical examination by the school physician 

seems to show that this child is suffering from 

You are advised to take 

this child to your family physician or a specialist, 

for advice and treatment as soon as possible, in order that the pupil 
may be better fitted to do successfully and without injury his school 
work. 

School Physician. 

This notice may be placed on a card of a certain color, 
say yellow, and about 53^ by 3 M inches in size. Some send 
all such messages by post, but this is in most cases a needless 
expense. 

On the back of the card may be printed a permit by the 
parent for the nurse to take the child to a cHnic or physician 
for medical or surgical treatment, and an alternative state- 
ment that the parent has had a physician and the result of 
the visit, somewhat as follows: 

PLEASE SEE THAT TmS CARD IS RETURNED TO THE TEACHER 

This pupil was seen by Doctor on 

, 19. . , with the following result 



Signature of parent or guardian, 



I desire the school nurse to escort my child to. 



for medical or surgical treatment of the. 
Signature of parent or guardian, 



STANDARDIZATION OF SCHOOL MEDICAL SERVICE ,197 

If the parent does not respond within three days, and an 
inspection at that time by the nurse shows no evidence of 
satisfactory treatment, another notice should be sent. 

If this notice is not heeded, and it should be printed and 
worded in such a manner as to command attention and get 
results, the nurse may visit the home to help the parent see 
the need of the treatment or to explain and arrange with 
her the free treatment at some dispensary, the school clinic, 
or other similar place. If the nurse is unable to get the 
treatment, and cannot do it herself, the physician, principal, 
or teacher may attempt the matter. 

So many parents are so poor and so ignorant, and the 
provisions for treatment are so inadequate or unsatisfactory, 
that men and women in the school medical service are soon 
driven to see the absolute necessity of an adequate school 
clinic, with an oculist to make eye examinations* and pre- 
scribe and, at times, furnish free glasses, dentists for dental 
service, and surgeons for operative work. The surgeons or 
the nurses attached, or a school physician, can make such 
treatments as are necessary — those for ringworm of the 
scalp with X-rays possibly, for favus, for trachoma, ade- 
noids, tonsils, etc. — and, with the help of the physical-edu- 
cation division, can give such medical gymnastics as are needed 
for orthopedic, mouth-breathing, and other cases. The need 
for an open-air school, and outdoor cooler ('^uncooked") and 
moister air in the classrooms, will also soon be made mani- 
fest in even the best of cities. 

As the examinations extend through the entire year, and 
the graduating class of February may not be reached by 
that time, it will be well to give this class an examination 
early in the term. Other children who may also be examined 
out of turn are: all the children of a family when a parent 
has come to the examination, as suggested, children going into 
athletic contests (very important in some cities), children 
who are especially referred to the physician by the nurse, 
or to the nurse by the teacher, and children who have entered 



1 98 EDUCATIONAL HYGIENE 

school, or that school, for the first time after the pupils of 
their rooms have been examined. 

Not only parental visiting at the examinations is desir- 
able, but also school consultations with nurse or physician, 
when the parent has neglected treatment for the child, for 
instance. A notice such as the following may be sent, at the 
end of the three-day period mentioned: 

DEPARTMENT OF MEDICAL SUPERVISION OF SCHOOLS 

Date J 19- •• 

To the parent or guardian of 

Public School 

You were notified a few days ago that this child was found on 
examination by the school physician nurse to be in need of immediate 
treatment for 

Please call at the school at o'clock 

to confer with the school physician nurse. 

Principal. 

Cross out either "physician" or "nurse" where they are 
printed for alternative use. This card may be white in 
color and 3 ^ by 5 H inches in size. Other devices to obtain 
treatment will be invented by the thoughtful and interested 
nurse, physician, or principal. Some cities use attendance 
officers to force children in whom the doctor or nurse will 
not admit till treated or cured. Notice is also sometimes 
sent that parents are keeping children out illegally, even 
though excluded or referred for treatment. 

When the time has come, three days after notification, 
and the pupil is in school, the teacher sends the pupil in for 
the nurse's or physician's inspection to see if the cure has 
been obtained. No record of cure or treatment is ever to be 
made without such inspection. The teacher's opinion is not 
enough. Doctor Foster, of Oakland, California, has his nurses 
record cures at the first routine inspection only, and these 
for ailments found the year previous. Cures take time. 



STANDARDIZATION OF SCHOOL MEDICAL SERVICE 1:99 

A further attempt at accuracy, co-operation, and a check 
on the work of doctor and nurse, is the principal's monthly 
report based upon his own and the teachers' records. This 
may be made very briefly as a part of the monthly report. 
The following tentative standard classification and termi- 
nology with probable frequency of ailments should be used 
for weekly and annual reports. 

School Ailments and Defects with Probable Number 

OF Ailments to be Found Among a Thousand 

Elementary Pupils 

I. NON-COMMUNICABLE AILMENTS 

A. Physical Defects. 

1. Adenoids, nasal obstruction, etc 50 

2. Anemia 10 

3. Deafness, defective hearing * 5 

4. Dental, teeth defects 660 

5. Enlarged tonsils 60 

6. Eyesight, vision defects 70 

7. Eyes crossed, strabismus, squint 7 

8. Glands enlarged, adenitis 10 

9. Heart defects 9 

10. Lungs very weak, not tubercular 5 

11. Malnutrition, debility, indigestion, "general condition" 20 

12. Mentality 10 

13. Nervousness, chorea, habit spasm, nervous exhaustion 2 

14. Palate defects 7 

15. Skeleton, orthopedic defects (flat-foot, club-foot, etc.) 2 

16. Spine: curvature, posture, round shoulders, etc 8 

17. Speech: stuttering, stammering, lisping, etc. 9 

B. Common Ailments. 

18. Abscess, boils, etc 5 

19. Acute sore throat, cough, etc 2 

20. Bronchitis i 

21. Cleanliness needed 20 

22. Catarrh, rhinitis 10 

23. Colds, bad. Coryza 30 

24. Ear discharge, otitis media 15 

25. Ears: earwax (impacted cerumen), foreign bodies, 

etc., minor 5 



200 EDUCATIONAL HYGIENE 

26. Eczema 7 

27. Eyes: "sore," blepharitis, sties, iritis, etc., minor... 20 

28. Headache (a symptom), migraine, neuralgia 15 

29. Laryngitis 5 

30. Nosebleed, epistaxis 2 

31. Pharyngitis, chronic sore throat 3 

32. Rheumatism i 

33. Sex ailments and habits 10 

34. Skin ailments, minor; herpes, seborrhcea, acne (black- 

heads) , etc 15 

35. Stomatitis, mouth ulcers, "canker sores" i 

36. Wounds, sores, sprains, poison-ivy, chilblains, "first- 

aid," etc 150 

37. Urinary ailments, incontinence of urine, eneuresis. . . 2 

II. COMMUNICABLE AILMENTS 

A. Parasitic and Minor Infectious Ailments. 

38. Conjunctivitis, "pink eye," etc 30 

39. Favus, yellow scalp sores i 

40. Impetigo "contagioso," infectious sores 20 

41. Influenza, grippe, infectious colds of a serious char- 

acter I 

42. Pediculosis, head lice and vermin 50 

43. Ringworm, body and scalp 4 

44. Scabies, itch 5 

45. Tonsilitis, quinsy 10 

B. Infectious Diseases. 

46. Chicken-pox 6 

47. Diphtheria 2 

48. Measles 4 

49. Mumps 4 

50. Scarlet fever 4 

51. Trachoma, "granulated eyelids" i 

52. Tuberculosis of the lungs, "consumption" i 

53. Tuberculosis of the bones and other parts of the body i 

54. Whooping-cough, pertussis 2 

Total i;409 

(D) Treatment, Cure, and Correction. — First-class school 
climes, as free to the children as text-books but carefully 
regulated by the school officials, are sure to be made a part of 



STANDARDIZATION OF SCHOOL MEDICAL SERVICE 20I 

all school systems, first in the poorer parts of the larger cities, 
but later everywhere. This is the cheapest and best means 
the community can take to develop real preventive medicine, 
for the small amount of clinic treatment in the child's school 
period, and before, will mean the early detection and eradica- 
tion of many grave pathological beginnings. A permanent 
tooth lost, for example, can never be replaced. It is gone for- 
ever; and no less an ideal than the saving of nearly all teeth 
up to the age of twenty and beyond can be long tolerated. 

But such thoroughgoing clinics will be long in coming, as 
shown in the chapter on that subject, and many substitute 
measures must be employed. Parents and family physicians 
must always be given the first chance for most ailments, 
even when their work is poor. Dental work may be accom- 
plished by the use of a travelling chair sent from school to 
school and manned by voluntary or paid dentists. It is com- 
paratively easy to get individuals or private organizations to 
give much valuable service in this direction. The splendid 
work being done abroad can be learned in Doctor Cruick- 
shank's volume on ^'School Clinics at Home and Abroad." 
No book has yet been written on the work being done in this 
country. 

(E) Prevention. — ^AU the work of medical supervision is 
preventive from the life standpoint, but the emphasis should 
be strong on this phase as in no other phase of human effort. 
The medical supervisor must interest himself in the physical- 
education department, not only for medical gymnastics 
and training of mouth-breathers, but for building up gen- 
eral bodily resistance and vigor. The consultation hours for 
mothers, now becoming common in schools, will help to get 
prevention at work very early with the little children yet in- 
fants. Co-operation with all agencies will centre the best ef- 
forts of the community on adequate health protection. 

Superintendent's Annual Report on Medical Inspection. — 
Much in the way of progress, records, and education of the 
public depends upon the character of this annual, public re- 



202 EDUCATIONAL HYGIENE 

port. The number of pages of the present reports devoted 
to this subject varies greatly even by percentages. South 
Manchester, Connecticut, probably gives a larger share of its 
report to these newer health matters than any other city. 
The plan of coming around to health matters every few 
years for intensive and comparative treatment, while emphasiz- 
ing certain general features every year, is to be commended. 
Some of the features of the regular report may well be : 

(i) The summary of the weekly reports, which have 
been summarized for the newspapers and for each monthly 
board meeting during the year, both as to ailments and the 
general features given on both sides of the weekly report. 

(2) Comparison with the work of former years. 

(3) Interpretation of the data presented. 

(4) Some of the interesting cases handled during the 
year, to give the intimate personal side, with photographs, 
if possible. 

(5) Emphasis on the percentage of ailments cured. 

(6) The principal needs and problems, and what parents 
can do to help. 

(7) Appreciative words for the various voluntary health 
agencies that have helped during the year, the newspapers, 
bequests for school clinics, etc. How the various divisions 
of the hygiene department have co-operated. 

(8) A general estimate of the health conditions of the 
school-children. 

Measuring the Efficiency of Medical Supervision Systems. 
— The principal efhciency tests are the percentage of the 
serious ailments existing in the school population that have 
been found and the percentage of the ailments found that 
have been cured. The decrease in ailments foimd from 
year to year due to prevention and curative measures (not 
to changes in the standards of inspectors) is a third essential 
factor. The estimate given above of the approximate per- 
centages of serious ailments to be found in an ordinary school 
population at the present time, may be used for comparison. 



STANDARDIZATION OP SCHOOL MEDICAL SERVICE 203 

Among a host of other tests of efficiency of this work are the 
following: 

(i) Number of physicians and nurses in proportion to the 
school population, and the number of nurses in relation to 
the number of physicians. 

(2) The qualifications and the character of the super- 
vision of these officials. 

(3) The percentage of the school population inspected and 
examined, and the frequency of these. 

(4) The quaHty of the reporting system, whether it em- 
phasizes essentials, and whether it promotes accurate records 
with minimum loss of time from other work. 

(5) The annual number of hours of work for physicians 
and nurses, and the regularity and punctuality of attendance 
upon such work. % 

(6) The reasonable freedom from epidemics, closing of 
schools, deaths of school-children, amount of exclusion, quaran- 
tine, illness, absence and elimination, etc. 

(7) The quality of the methods of doctors and nurses, to 
be determined by expert observation. 

(8) The amount of State-aid money obtained because of 
efficiency demonstrated to the State Supervisor of Hygiene. 

Note. — Complete explanation of this plan of health supervision may be 
found in the editor's volume entitled, " The Administration of School Medical 
Inspection," published by Teachers College, Columbia University, New York 
City. 



CHAPTER XII 
THE SCHOOL NURSE AND HER WORK^ 

The Introduction of Nurses. — It was the introduction of 
the trained nurse to the work of school medical inspection 
that revolutionized the health supervision of school-children. 

In England, in 1893, we have the first definite record of 
the work of the school nurse. This work was done voluntarily 
by Miss Amy Hughes, a member of the Metropolitan Associa- 
tion of Nursing, who was asked by one of the managers of a 
poor school in the Drury Lane district in London to visit the 
school and attend to the children's small ailments. The result 
was most beneficial. In 1898 a voluntary association was 
formed, called the London School Nurses' Society. The 
following circular was prepared and issued by it: 

The London School Nurses' Society has been formed with the 
object of supplying visiting nursing to elementary schools in poor 
districts. Already three nurses visit some of the poorest schools and 
attend to the small ills of the scholars — such as sore heels and inflamed 
eyes. 

Excellent results follow their ministrations: each is able to visit 
four schools in one day, and see about one hundred children, who are 
sent to her one by one by the teachers. It is hoped that the work of 
the London School Nurses' Society may be done wherever possible by 
a Queen's nurse, and so avoid the multiplying of agencies. The 
Jubilee Institute has approved of school nurses in principle. Probably 
it will be difi&cult to impress on the public the importance of the work 
to be done, or the necessity for these nurses; but it must be remem- 
bered that the sore heel soon becomes poisoned if left to London dirt, 
and the inflamed eyes often lose all power of seeing simply through 
neglect. There is no surer way of securing the health of the people 
than to arrest small ills at the beginning; a nurse can see at a glance 

1 See also the chapter on "The Professional Trainiog of School-Health 
Workers." 

204 



THE SCHOOL NURSE AND HER WORK 205 

whether a child should be sent to a doctor; she can impress cleanli- 
ness; she can follow up bad cases to their homes; she can recognize 
the early symptoms of fevers, and do much to stop the spread of those 
infectious diseases which so often devastate our schools. It is found 
that cases of bad eyes and dirty heads are practically stamped out 
of a school by six months' regular visiting; consequently each nurse is 
able to enlarge the scope of her work as time goes on. 

In 1904 the London county council took over the work, 
thus placing it under municipal control. But it was in 1902 
that school nursing was first put on a municipal basis, and 
New York City claims the credit for this forward step. 

New York City History. — Medical inspection of schools 
had been established for many decades before this, but the 
results were far from satisfactory. The history of school 
nurses in New York City is particularly interesting, inasmuch 
as those who suggested and helped to work%out the scheme 
of school nursing are still actively engaged. 

The suggestion came from Miss Lillian D. Wald, who was 
talking over the health problem of the schools with Doctor 
Lederle, Health Commissioner of New York City, and Mr. 
Charles BurHngham, chairman of the Board of Education. 
The question under discussion was: "What is to be done with 
all the children who are excluded from school for minor con- 
tagious diseases by the medical inspectors?" Miss Wald at 
once said: ''Try a nurse." She herself is a nurse and always 
sees the great possibilities in new opportunities; so, after some 
further discussion, it was decided to see what a nurse could do 
for the children in the schools, and for the return of those 
who were excluded. The writer was asked to make the ex- 
periment, and on September i, 1902, began by selecting for 
test purposes four of the large down-town schools.^ 

First Duties. — The first duty was to visit the school prin- 
cipals and explain the work. As no rooms were available, 
any corner of the schools which could be utilized was selected. 

^ Thus the writer of the chapter has the honor of being the first municipal 
school nurse. — Ed, 



2o6 EDUCATIONAL HYGIENE 

Arrangements were made to have all children examined by 
the medical inspector sent to the nurse, who treated the 
minor cases in the school; the remainder were taken to dis- 
pensaries, except those who were excluded for the major con- 
tagious diseases, such as scarlet fever, measles, etc. A Ust 
of the children excluded was obtained from the principal, 
and these were looked up and returned to school as soon as 
possible. An hour daily was spent in each of the four schools, 
and a regular time-table followed. The supplies used were 
generously donated by the Nurses' Settlement. A course of 
treatment was outlined and submitted to the Department of 
Health, which with a few revisions is in use at the present 
time. This course of treatment is about as follows: 

Treatment. 

Pediculosis. — Saturate head and hair with equal parts of kerosene 
and sweet oil; next day wash with a solution of potassium carbonate 
(one teaspoonful to one quart of water), followed by soap and water. 
To remove "nits" saturate hair with hot vinegar. 

Favus, Ringworm of Scalp. — Mild cases: Scrub with tincture of 
green soap, cover with flexible collodion. Severe cases: Scrub with 
tincture of green soap, epilate, paint with tincture of iodine, and cover 
with flexible collodion. 

Ringworm of Face and Body. — Wash with tincture of green soap 
and cover with flexible collodion. 

Scabies. — Scrub with tincture of green soap, apply sulphur oint- 
ment. 

Impetigo. — Remove crusts with tincture of green soap, apply white 
precipitate ointment (ung. ammon. hydrarg.). 

Molluscum Contagiosum. — Express contents, apply tincture of 
iodine on cotton toothpick probe. 

Conjunctivitis. — Irrigate with solution of boric acid. 

Supplies. — ^Later the Board of Education provided the 
following supplies: 

1 screen. 

2 chairs (i high). 
I cabinet. 

I table. 



THE SCHOOL NURSE AND HER WORK 207 

1 scrap-basket. 
12 towels. 

2 pounds absorbent gauze. 

I dozen bandages (assorted sizes). 
I pound boracic-acid powder. 
I quart tincture of green soap. 
4 ounces collodion. 

1 pound vaseline. 

4 ounces white-precipitate ointment. 

2 basins (white granite). 
I glass jar (i gallon). 

I ointment jar (glass). 

100 bichloride-mercury tablets (to be kept in safe place). 

These were ordered by the principals with the other 
regular school supplies and replenished when necessary. 

Municipal Appointment. — On November 7, 1902, the 
Board of Health appointed its first school n%irse, Miss Lina 
L. Rogers, R.N. In December of the same year twelve 
nurses were appointed, and their work for one month proved 
of such value to the community that the Board of Estimate 
appropriated $30,000 for school nurses for the year 1903. 
This is the beginning of what has developed into one of the 
most efficient social service organizations of the present day — 
three hundred and sixty-five school nurses being now employed 
by the Board of Health of New York City. 

Growth of Nurses' Work. — In the beginning of the work 
the nurses' duties were limited to treating the children ex- 
cluded by the medical inspector and to making home calls to 
explain what treatment was required for the excluded child. 

Later on classroom inspections were added to the nurses' 
duties, giving the medical inspectors more time for the phys- 
ical examinations. The opportunities for far-reaching social 
service became evident on the first visits to the homes. 

Classroom Inspection. — In making the classroom in- 
spection the nurse took her position by a window so that she 
might have a good Hght for the inspection of the child. The 
eyes, ears, nose, throat, skin, and hair were all examined for 



208 EDUCATIONAL HYGIENE 

evidences of disease or defect. Wooden tongue depressors 
were used for examining the throat, one for each child, and 
where any symptom of diphtheria was found the child was 
sent home. Where any defect was present the children were 
referred to the medical inspector. His duty was to make a 
diagnosis. A code was devised by which numbers could be 
used instead of the name of the disease, to conceal from chil- 
dren the name of the disease, and to lessen the clerical work. 



Code Used. 



CODEi 



1. Diphtheria. 12. Varicella. 

2. Pediculosis. 13. Pertussis. 

3. Tonsilitis. 14. Mumps. 

4. Pediculosis. 15. Zero. 

5. Ac. conjunctivitis. • 16. Scabies. 

6. Pediculosis. 17. Ringworm. 

7. Trachoma. • 18. Impetigo. 

8. Pediculosis. 19. Favus. 

9. Zero. 20. MoUuscum contagiosum. 

10. Scarlet fever. 21. Acute coryza. 

11. Measles. 

Zero numbers are given to children having no disease, 
so that all should be given a code number. No feeHngs were 
hurt by the method. 

Home Visits. — The nurse took charge of the child after 
the diagnosis, and by persistent effort and many visits to 
the home, finally persuaded the parents to have the defect 
remedied or disease treated. It is this following up and point- 
ing out the danger of neglect that means so much to the child 
and to the success of school medical inspection. The whole 
aspect of the school medical work has changed since nurses 
have taken such a prominent part in it. It is no longer 
medical inspection of schools. It is medical or health super- 
vision of school-children. The child has a future, and some 
one must in dead earnest point it out to the parents who fail 
or refuse to see it. 

» See also code in preceding chapter, prepared by the editor. 



THE SCHOOL NURSE AND HER WORK 209 

School Boards' Duty. — Right here it may be said that some 
boards of education are not doing their full duty toward the 
children under their charge, by forcing them to study while 
they are physically unfit. Where now employed, the school 
nurse's duties are numerous and varied. Besides making the 
classroom inspections and referring the cases to the medical 
inspector she is called upon to do much of the scientific work. 
In some cities the school nurse takes the swabs for throat 
cultures, and excludes all suspect cases of diphtheria, scarlet 
fever, measles, etc., as soon as discovered, notifying the 
medical inspector of such exclusion as well as the health de- 
partment. She is also permitted to treat eye diseases in school 
according to the physician's order. 

Drills. — She is responsible for the conditions of cleanli- 
ness of the mouths of the school-children as well as their 
general cleanliness. Tooth-brush drills are Carried on regu- 
larly and efficiently in the schools by the nurse. Nose-blowing 
drills are no longer a fad but a recognized necessary aid to 
general health habits, and the nurse is the one who sees that 
this is regularly carried out. It was a nurse who originated 
these drills in the schools.^ Even now we are learning that 
this has a very marked effect on the breathing of the children, 
inculcates cleanly habits, and keeps the air in the classroom 
purer. Teachers are beginning to see the valuable effect of 
it on their own health. 

In the visits to the homes even greater good is being 
done by the school nurse. Here she imparts instruction on 
the care of the body, the value of clean surroundings, of 
wholesome food, of proper clothing, and of right habits of 
living. She discovers all kinds of unhealthful conditions, 
concealed cases of contagious disease, rooms without air or 
light, overcrowded homes where bad moral conditions exist, 
filthy drains, and leaky plumbing. These and other conditions 
are being constantly reported by the school nurse to the 
proper authorities, and adequate relief obtained from the 
proper sources. 

^ The writer herself . — Ed. 



2IO EDUCATIONAL HYGIENE 

Rural School Nursing. — In rural communities health 
supervision of school-children is quite as important as in the 
cities. It is not possible for many of the smaller municipal- 
ities to provide a medical inspector, nor is it always necessary. 
If a properly qualified nurse is employed she can urge the 
parents to consult their own family physicians, and in this 
way have almost all defects removed or diseases cured. It 
will not be necessary for one school to have a nurse devote 
her whole time to it. Several districts could unite and have 
the nurse spend one day a week in each. This would divide 
expenses and give a good service. Each school should be 
visited frequently to note progress, to urge the practise of 
hygienic measures advised, such as the drills, and to give 
talks on proper food, ventilation, dental care, etc. 

Relief Organizations. — One of the school nurse's duties 
will be to find out all the reHef agencies in her district or dis- 
tricts. If there is no dispensary, she will be the one to find 
ways and means to estabHsh one. If the authorities cannot 
aid, some influential women in the neighborhood should be 
induced to unite and have it started. If relief is required, 
similar means are taken to secure it. Everything, of course, 
should be done so far as possible by the municipal authorities. 

I believe that the school board should furnish freely every- 
thing that is necessary for the child's health and strength, 
such as food, clothes, and medical attention, wherever it 
cannot be furnished by the home. Otherwise it is waste of 
money to try to educate the child. A weakened brain cannot 
be active and receptive; therefore strengthen it so that it can. 
Children who are anemic and undersized should be kept in 
the open. The school nurse should urge that children be 
taught in the open all day in country schools as well as the 
'city, and what is good for the delicate in this instance is 
equally good for the strong. Let us have no walls for schools 
when it is possible to do without. 

Little Mothers' Classes. — The school nurse also should 
start Httle mothers' classes in the school as soon as she begins 



THE SCHOOL NURSE AND HER WORK 211 

work. Inestimable good will be done by having these girls 
taught how to do the essentials of home-making. Gradually 
they grow into the habit of wanting to know the reasons for 
this and that, and before long the nurse finds she is a teacher 
in sex hygiene in the most natural way. Teach the girls to 
bring their baby sisters and brothers, so that they may learn 
how to bathe them and note any abnormalities; show them 
how to make a bed properly; to prepare food for the baby; 
to make clothes for it; and to look for any unusual conditions 
in the children of the families who are their friends. 

School Dental Chairs. — Here is the beginning of a great 
work in the development of the future race, in looking after the 
teeth. The *' little mothers" will soon learn to look for the 
first tooth, and to keep it clean. If this interest is aroused 
and right habits formed we shall not need to fear for the future 
of the children's teeth. 

It is very necessary that all the school-children have 
regular, systematic dental care. To this end, wherever possi- 
ble, have a dental chair placed in the school. Experience has 
proved that the installation of dental chairs in the schools is 
not a difficult undertaking and is money saved many times 
over. 

In Toronto, Canada, the school nurses subscribed $500 
and presented it to the Board of Education for the equipment 
of a dental room in one of its schools. In addition the Board 
installed three chairs in other schools. This year six more 
schools have been equipped with dental chairs. A dental 
surgeon works from nine to twelve daily, and on Saturday 
from nine to eleven. Many methods may be used to get the 
money and permission for the first experiments.* 

The Qualifications of a School Nurse. — The nurse who 
would be a successful school nurse must have a special train- 
ing for the work. In addition to the general training in a 
hospital which has wards set apart for eye, ear, nose, throat, 
and skin diseases, she should have a course in district nursing. 

* See chapters on co-operation and initiation of school-health measures. 



212 EDUCATIONAL HYGIENE 

This is most important, as it brings the nurse in contact with 
home conditions. Here she learns how it is sometimes next 
to impossible for the parents to get things done, owing to all 
sorts of unfortunate conditions. 

A capable, intelligent nurse who knows the agencies in 
her district can often reheve serious situations at once by a 
few helpful suggestions as to how relief may be obtained. 
The school nurse should have a healthy, pleasant appearance. 
The nurse who fails to keep herself tidy and neat, and whose 
teeth are not in good condition, does not gain the confidence 
of the children, and her work is never successful. 

The school nurse should have a broad social outlook. 
She must be a power in the community in which she works. 
She must know how to meet rich and poor ahke, and this is 
where tact, good sense, and sound judgment are required. 
She must know how to avoid hurting the feeHngs of the family 
physician. 

The most essential requirement is thoroughness. Every 
detail should be recorded for future use — some may be mental 
notes. One nurse reported ninety-nine visits to one family 
before she got results.^ 

Controlling Authority. — ^The school nurse should be em- 
ployed by the board of education or board of school trustees 
as one of the regular school staff. This avoids two authorities 
controlling the school work. The teachers give heartier co- 
operation to one of their own associates, and all are working 
ultimately for the same result — to make the school-child a 
better citizen both physically and mentally. This has been 
clearly demonstrated since the school nurses became a part 
of the medical-inspection system. 

Rules and Regulations. — In one of the larger cities the 
following general rules and duties of nurses have been adopted: 

*Here is where legal compulsion can frequently be used to advantage. — Ed. 



THE SCHOOL NURSE AND HER WORK 213 



GENERAL RULES 

As teachers, nurses, and medical and dental inspectors are all em- 
ployed by the board of education, and as all are working for the fullest 
development of the children, educationally and physically, it should 
not be necessary to ask for hearty and harmonious co-operation in the 
work. 

Always be courteous and sympathetic with parents and children, 
and thus avoid much needless resentment. 

Absolutely no suggestions as to treatment shall be given except 
as hereinafter directed. 

Medical inspectors and nurses must promptly report all dis- 
covered cases of contagious disease to the board of health, thus ren- 
dering efficient assistance in eliminating this menace to the community. 

The following diseases must be referred to the principals for ex- 
clusion: smallpox, scarlet fever, diphtheria, measles, German measles, 
mumps, chicken-pox, acute tonsilitis, whooping-cough, open cases of 
tuberculosis, and such diseases of skin, scalp, and ^e as, in the judg- 
ment of the medical inspector, should be excluded. 

Except in case of sudden illness, request for leave of absence 
must be forwarded to the department of medical inspection at least 
one week before such leave is required. In case of inability to report 
for duty on account of illness, notify the department of medical in- 
spection by telephone. 

A written notification must follow within twenty-four hours. 
When reporting for duty after absence, a certificate of illness from the 
attending physician must be presented. 

Daily reports must be forwarded in time to reach the department 
of medical inspection by the first mail on the following morning. 

At each school visited, a time-book must be signed, stating the 
time of arrival and departure. All cases requiring treatment must be 
referred by card, in sealed envelope, to the family physician. Medical 
inspectors and nurses must not remove the clothing for examination 
of children, " without consent *' or in the presence of parent or guardian. 
Medical inspectors and nurses must not interfere in any way with 
the school discipline. 

Duties of Nurses 

Each nurse is assigned to a group of schools. 
The hours of duty are from 9 a. m. to 4 p. m., and Saturday, 9 a. m. 
to 12 noon. 

Each nurse shall prepare a time schedule for her group of schools 



214 EDUCATIONAL HYGIENE 

which must be forwarded to the superintendent of nurses for approval; 
a copy must be given to each principal. 

Each nurse must see cases referred to her by the medical inspector 
and deal with them as directed. 

Morning Inspections and Treatments. — In a room designated for 
the purpose the nurse must receive each morning all children referred 
to her by the medical inspector, and give instructions or treatment as 
follows: 

Pediculosis. — Children affected with pediculosis are to be instructed 
as to methods of home treatment. Each child must be given a copy of 
the official circular, entitled "Instructions to Parents on the Care of 
Children's Hair and Scalp." These children are to be instructed to 
report to the nurse at her request, and at such times are to be exam- 
ined for evidence of treatment. In instances of persistent neglect, the 
child is to be referred to the medical inspector for exclusion. 

Eye and Skin Diseases. — Methods of treatment to be employed. 

Favus. — Mild cases: scrub with tincture of green soap and cover 
with flexible collodion. Severe cases: scrub with tincture of green 
soap, paint with tincture of iodine, and cover with flexible collodion. 

Ringworm of Scalp. — Treatment as in favus. 

Ringworm of Face and Body. — Wash with tincture of green soap 
and cover with flexible collodion. 

Scabies. — Wash with tincture of green soap, and apply sulphur 
ointment. 

Impetigo. — Remove crusts with tincture of green soap, and apply 
white-precipitate ointment (ammon. hydrarg.), lo per cent. 

Conjunctivitis. — Irrigate with warm solution of boric acid. 

Instructions for Physical Defects.— The nurse must obtain each day 
from the medical inspector a record of the physical defects of each case 
examined on that day. When necessary the nurse may request the 
parents to confer with her at the school regarding the treatment for 
the child. 

The dates of these consultations must be noted on the nurse's 
record copy. The nurse will note on the physical-record card the 
nature of the treatment received from the family physician. 

Emergency Cases. — In the absence of the medical inspector the 
nurse will give first-aid treatment, referring all such cases as require 
it to the family physician. In the absence of the medical inspector 
any suspected case of major contagious disease should be referred 
to the principal for exclusion, and should be reported immediately 
by telephone to the department of medical inspection, giving child's 
name and address. A written report must be mailed the same day. 

The nurse must be ready to give any information to the principal 



THE SCHOOL NURSE AND HER WORK 215 

as to the children under her care. A child must not be sent from 
school without the consent of the principal. 

Routine Inspection. — The nurse must make a fortnightly routine 
inspection of the children in the classrooms. The eyelids, throat, 
skin, and hair of each pupil are to be examined. 

The children are to be instructed to pull down the eyelids, open 
the mouth, and show the hands. Wooden tongue depressors are 
furnished by the department, and a separate one must be used for 
each child where such use is necessary. No tongue depressor is to he 
used more than once under any circumstances. 

All cases of suspected minor contagious disease found are to be 
noted on the class record cards, with the data, in appropriate columns. 

The class record cards must be kept in an accessible place in each 
school in charge of the nurse. Code numbers or letters must be used 
to indicate the disease. 

All suspected cases of contagious eye and skin disease found are 
to be referred to the medical inspector for diagnosis. 

Home Visits. — When cases referred by the medical inspector 
have not been given treatment in a reasonable time, the nurse must 
visit the parents at home to explain the condition and the necessity 
for treatment. The nurse must give general directions regarding 
proper food, ventilations, cleanliness, and general hygiene. Revisits 
must be made in each instance until evidence of treatment is shown, 
or parents refuse treatment. No case must be terminated on account 
of inability to obtain treatment until it has been referred to the 
medical inspector. 

If the parents are unable to take the child to a dispensary, the 
nurse may do so, but must previously obtain in writing a request to 
that effect, signed by the parent or guardian. 

No visit shall be made to contagious cases. 

Home visits and visits to hospital or dispensary must be noted on 
the nurse's record copy. The form must then be submitted to the 
medical inspector, who will sign it if the evidence is satisfactory. 

Evidence that a child is under medical care is sufficient for ter- 
minating the case. 

Meetings. — Nurses must report regularly, in person, at such times 
as may be designated, to the superintendent of nurses. 

In Conclusion. — The possibilities of the work of the school 
nurse and the opportunities afforded her of doing real con- 
structive work, both in the schools and in the homes, cannot 
be estimated. The bond of friendship which exists between 



2l6 EDUCATIONAL HYGIENE 

the school nurse and the mother in the home makes it pos- 
sible to secure for the children from infancy onward a far 
greater degree of care than would, or could, otherwise be 
given. The school nurse has it in her power not only to 
remedy the existing conditions which are menaces to right 
living but has also the opportimity to open up new avenues 
of social service. Her work is not alone with those who have 
defects or disease but very largely with those who are well. 
Her duty will become more and more the supervision of the 
life habits of the well; therefore much more teaching of the 
laws of health will be observed and the result to humanity 
can better be imagined than described. Nurses have a splen- 
did opportunity for fitting themselves for this new field in 
nursing by taking a course at Teachers College, Columbia 
University, where the practical training is also provided. 



CHAPTER XIII 
SCHOOL FEEDING 

School Feeding as an American Problem. — The school 
lunch has always been an important part of our American 
school life. The noon hour plays a prominent part in stories 
of the little old red schoolhouse of former days. It was 
then that the pent-up energy of social longings found relief, 
and the most enduring companionships were formed. Al- 
most all of the young people stayed at the school during the 
noon hour and ate lunch together because few of them lived 
near enough to go home. This condition still prevails in 
rural districts, but where urbanization has taken place schools 
and homes have been brought nearer together in distance 
and the school lunch has largely disappeared. 

But there is one kind of school — the high school — in 
which the old order has never changed. This is because in 
towns and smaller cities there is usually but one high school, 
and even in larger cities each school serves a large district. 
The consequence is that the children have a long way to go 
to reach their homes, and so we have developed the single 
session extending over the noon hour and broken by a short 
lunch period. As a result, in himdreds of high schools through- 
out the land, groups of young people numbering from a score 
to many thousands in each locality are every day confronted 
by the alternatives of going hungry, eating a lunch brought 
from home, or buying one near or in the school. 

How the High School Meets the Problem. — ^The many 
ways in which the high schools meet or fail to meet the prob- 
lem may be summarized under the two headings of no pro- 
vision and supervised provision, either indirect or direct. 

217 



2l8 EDUCATIONAL HYGIENE 

The first method is rapidly becoming less common. 
Under it the school authorities pay little attention to what 
the young people eat during the lunch period, or where they 
eat it, so long as they do not annoy the teachers or litter the 
premises. The results are socially unwholesome and phys- 
iologically unhealthy. The breaking of bread with one's 
fellows is an important social matter and the conditions sur- 
rounding it should be as comfortable and cheerful as circum- 
stances permit. 

The health considerations are more important. Where 
no place is provided in which the boys and girls can eat their 
lunches conveniently and in leisure, there is every temptation 
for them to eat nothing at all, or to eat little and bolt that 
little down with the greatest possible speed. 

These conditions are frequently but slightly bettered 
when the school authorities sell to the janitor or some caterer 
the privilege of maintaining a lunch-room in the school build- 
ing without official supervision or control. 

The second form of solution came into being when Bos- 
ton, in 1894, determined to grapple with the high-school 
lunch problem and solve it. In that year Mrs. Ellen H. 
Richards was instrumental in getting the school board to 
decide that all selling and serving of food in its high schools 
must be done with its approval and under its supervision. 
An arrangement was made with the New England Kitchen 
through which wholesome lunches were prepared and dis- 
tributed to the city high schools. This plan was successful, 
and has been developed until at present the fifteen pubhc 
high schools of Boston are daily suppHed with Imiches pre- 
pared by the New England Kitchen and sold to the students 
at cost. The rooms and equipment are furnished by the 
city and a committee of high-school masters supervises the 
work. At present the school board is considering taking over 
the lunch-rooms for direct control. 

An example of the direct provision of high-school lunches 
is furnished by Philadelphia, where the work in every school 



SCHOOL FEEDING 



219 



is financed and controlled by the board of education. The 
superintendent of this lunch system has the rank of super- 
visor in the school government. She is an expert dietitian. 



Penn^y Lunches 

bought 
at 

School ,u 

Calories 




Penny Lunches 

bought 

on 

Street 


Bean Soup 


■ 




Sausa^e&Roll 


Rice Pudding 


H 




Pretzel 


Cocoa 


H 




Cinnamon Bun 


Milk 


H 




Ice Cake 


Ro^al Lunch 


H 




MarshmallowCake 

52 


Graham Crackers 


1 




Calories 


Popcorn po! 1 


Spice Wafers 


1 




1 


Candy 1.%% 


Dartes 


1 




1 


Licorice 


Sweet Chocolate 


1 




I 


Chocolate Rppermint 


Stick Candy 


■ 




" 


Candy Roll 



RELATIVE FOOD VALUE OF SCHOOL AND STREET LUNCHES 

The left-hand column represents the food value of a penny portion bought 
at school when a charge of one-quarter of a cent is made for service. The 
right-hand column shows the food value of the amount purchased for a cent 
from the street vendor, who makes all he can on the deal. 

At school the amount of food given for one cent is always as high as possi- 
ble. In the street the child can buy something which is not food at all, like 
licorice. 



In addition to supervising the preparation of the lunches, 
she spends several hours daily teaching classes about food 
uses and values. In this teaching the school lunches are 
used as examples of economical, carefully planned, and 
wholesome meals. One of the lessons is that the typical lunch 
at school, costing ten cents, gives seven hundred calories, 
while crullers and coffee, a common meal where lunches are 



220 EDUCATIONAL HYGIENE 

unsupervised, yields but two hundred and fifty calories for the 
same price. 

Another example of municipal high-school lunches is 
afforded by Rochester. Since 1903 the two high schools of 
that city have conducted lunch-rooms directly managed by 
the board of education. The kitchens and dining-rooms, 
instead of being adapted basements, were provided for in 
the original plans of the buildings, and as much attention was 
given to their construction and location as was devoted to 
any of the other rooms. 

The dining-rooms are light and airy, open to the direct 
rays of the sun, and have a seating capacity of one thousand 
pupils each. The kitchens are well equipped with such me- 
chanical contrivances as steam cookers, dish-washers, and 
potato-peelers. The cooking is done by utiKzing the waste 
steam from the general heating plant, so that there is no extra 
expense for fuel. An experienced dietitian, appointed by the 
board of education, superintends the entire work of pur- 
chasing, preparing, and selling the food. There are five 
workers in each school who cook and serve the meals. 

These lunch-rooms are entirely self-supporting. As les- 
sons of experience have made the work more efficient, the in- 
creasing profits have been devoted to providing more food 
for every five-cent piece paid by students, instead of turning 
the extra revenue back into the city treasury. The result is 
that each year has seen an increase in the amount of food 
purchased for five cents, until at the present time this sum 
secures for the children generous portions of well-cooked 
roast beef or roast lamb. 

Other articles of food are correspondingly cheap. Soups 
cost five cents, desserts five cents, a large plate of macaroni 
with cheese and bread five cents, half a pint of certified milk 
three cents, a buttered roll one cent, and a bread-and-butter 
sandwich one cent. 

The money received from the sale of food at these prices 
covers not only the entire cost of the food itself but that of 



SCHOOL FEEDING 221 

all the salaries of attendants and supervisors, besides the 
upkeep of equipment. 

The work done in Rochester and Philadelphia is perhaps 
more highly developed than is general elsewhere, but never- 
theless it is only a sample of what many cities are doing. 

Administration of High-School Lunches. — The New York 
School Lunch Committee in a recent inquiry found that of 68 
cities, ^S furnished students of the high schools with lunches 
directly; i8 had farmed out concessions to commercial ca- 
terers; 7 allowed co-operative student organizations to fur- 
nish lunches under supervision of the board of education; 
and in 5 cities lunches were sold by private philanthropic 
organizations, such as women's clubs, etc. In practically all 
cases the cities supported the lunches to the extent of the 
overhead charges. There is no doubt that high-school 
lunches are to-day practically recognized as*a legitimate part 
of public-school provisions. 

The general features of administration in sixteen typical 
cities are shown in the following summary based on data 
gathered by the Committee on High School Lunches in Bos- 
ton in 1913. The cities included are: Brooklyn, New York, 
Buffalo, Rochester, Springfield, Fairhaven, Newtonville, 
Philadelphia, Pittsburgh, Cincinnati, St. Louis, Kansas City, 
Grand Rapids, Minneapolis, Omaha, and Seattle. 

In all these cities the financial risk is finally lodged with 
the school board. Immediate responsibility for administra- 
tive detail rests with the domestic-science department in 
eight cities. In five cities the work is controlled by a special 
committee of the board. In two cities, where only one high 
school has the lunch, the work is directed by members of the 
faculty; and in the remaining city by the High School Students' 
Association. 

In a number of cities they had first tried out the experi- 
ment of having janitors or caterers serve the lunches, but in 
four cities where the work is relatively new it was begun im- 
mediately under school-board control. In St. Louis and three 



222 EDUCATIONAL HYGIENE 

other cities the school-luncheon work is under the supervision 
of the domestic-science department, and cooking classes oc- 
casionally provide food for the lunch-room. This works out 
particularly well in the smaller cities where the numbers are 
not so large — as, for example, in Newtonville, Mass. In at 
least one case the money is handled by the commercial de- 
partment of the high school. In Philadelphia the superin- 
tendent of lunches gives talks at the different high schools on 
lunches and dietetic principles involved. 

There has been practically no attempt to connect the work 
in the high schools with the health department, though this 
connection is an important feature of the lunches in ele- 
mentary schools. In Pittsburgh this was proposed and ap- 
proved by the board, but had not been put in operation ac- 
cording to the last report. In only one city was the director 
reported as not specially trained for the work. In thirteen 
cities the superintendent of lunches ranks as a regular 
school officer, being either supervisor or a member of the 
faculty. 

In nearly all the cities the surplus is designed for im- 
proving the lunches themselves, as, for example, reducing the 
price of foods served or buying new equipment. In a few 
cities, however, the money is returned to the general school 
fund, and in Springfield it is turned in to a common revenue 
fund for the city. 

It is practically a universal custom to charge enough for 
the lunches to cover food and service. In a majority of cases 
enough is charged to cover the cost of ice, the upkeep of 
equipment, and repairs. The cost of superintendence is 
covered in eight cases, and fuel in five. Light, heat, rent, 
and water-rates are not included in the cost. 

The School-Lunch Problem in Elementary Schools. — ^The 
essential features of the planned and supervised lunch in the 
best high schools are that the child's need is provided for, the 
food is sold at cost, and it is wholesome and well served. The 
lunch-rooms are cheerful, pleasant, and sanitary, and the work 



SCHOOL FEEDING 223 

is under responsible management. Moreover, there is no 
compulsion, actual or implied, put on any child to buy the 
school lunch — he is simply given the opportunity. 

The question that school workers are now asking is: Why 
cannot the same benefits be secured for the vastly larger 
number of elementary-school children? In the smaller towns 
and country districts the younger children face the same noon 
problem as their older brothers, with the difference that they 
have a longer afternoon session of work ahead. In mill and 
factory towns and in the poorer districts of the large cities, 
even when the children go home at noon, there is frequently 
no one there to prepare lunch. Both father and mother are 
absent at their work. Moreover, ignorance about nutritive 
food and its preparation is so dense and so wide-spread that 
thousands of children start for school in the morning after a 
totally insufficient breakfast consisting, for instance, of coffee 
and bread, and taking with them a few pennies to buy lunches 
in the shops near the school. In consequence they must wait 
until night before they get a real meal. 

The fact that more than fourscore cities are already tak- 
ing steps to meet this problem shows that it is real, wide- 
spread, and serious in degree. The first question which con- 
fronts every one of these cities, as well as the others which 
have not yet begun to provide for school lunches in elementary 
schools, is whether or not this work is a legitimate function of 
the board of education. 

Objections to School Feeding. — When the project of in- 
augurating school feeding in elementary schools is proposed 
to the taxpayer, the citizen, or the school man, the immediate 
reaction is almost always one of opposition. The expression 
of this opposition takes many forms, among which the fol- 
lowing arguments are usually prominent. School feeding, it 
is claimed, would further complicate the already intricate 
systems of public education; it would add to the work of 
already overburdened teachers. The providing of school 
meals would tend to lessen the responsibility of the home and 



224 EDUCATIONAL HYGIENE 

SO undermine the foundations of family life. If meals are 
provided at all, they tend to become not only free but uni- 
versal, which would result in pauperizing the community. 
As some children would receive meals and others not, the 
system would tend to promote undesirable distinctions among 
the children. If children are genuinely underfed at home, the 
provision at school of one meal per day will not solve the prob- 
lem of their proper nourishment. 

The foregoing arguments are the most important of 
those commonly urged against school feeding and are fairly 
typical of the rest. On careful analysis, all of these argu- 
ments fall into two classes. In the first come those objec- 
tions which form one or another feature of the general argu- 
ment that the providing of food is not a legitimate function of 
a department of education. The objections of the second 
class include arguments that school feeding is socially danger- 
ous. It seems worth while briefly to consider whether or not 
the objections against school feeding are so important and 
valid as permanently to exclude it from among the possible 
activities of the modern socialized school. 

To the first objection, that furnishing food is not a legiti- 
mate function of a department of education, it may be answered 
that under our systems of compulsory education the power 
to force every child to attend school carries with it the duty 
of making it possible for every child to learn. If the child is 
so hungry that he cannot learn, some means must be pro- 
vided whereby he shall be fed. Hunger is a stern condition, 
not a social theory. It cannot be met through the offering of 
a geography or a grammar. It is clear that where social con- 
ditions exist which involve the presence in school of large 
numbers of unfed or underfed children, it is the function of 
the school to see to it that some means be provided whereby 
these children can obtain food in order that they may be in 
condition to obtain knowledge. This does not necessarily 
involve provision by the school itself. It does involve the 
facing of the problem and the securing of some solution 
for it. 



SCHOOL FEEDING 22 5 

The arguments of the second class claim that school feed- 
ing is socially dangerous, that it tends to undermine the re- 
sponsibility of the home, and that it results in governmental 
paternahsm. 

There is one nearly universal fallacy in the reasoning that 
lies behind these arguments. This is the assumption that 
any form of school feeding means the free provision of meals 
for all children. This assumption is unwarranted by the 
facts either here or abroad. Such work as that already de- 
scribed as being carried on in the high schools of Rochester, 
Boston, Philadelphia, and other great cities has no remote 
suggestion of the dispensation of alms. What it does provide 
is the opportunity to purchase wholesome food at cost. This 
is what school feeding in America has meant up to the present 
time and, so far as we can foresee, it is in tjie main what it 
will continue to mean. Moreover, it is in large measure what 
school feeding means abroad. 

Elementary-School Feeding and Medical Inspection Anal- 
ogous. — ^There is a close analogy between the extension of the 
school's activities to provide an opportunity for purchasing 
food, and the existing systems of medical inspection which 
examine children and notify the parents of the steps which 
need to be taken to put them in such physical condition that 
they can benefit by the free education provided by the State. 
Both are extensions of social machinery which provide oppor- 
tunity for, but do not supply the remedy for, the wrong condi- 
tion found. The sort of school feeding which we are discuss- 
ing provides machinery for finding out which children need 
food, and for giving their parents an opportunity of remedy- 
ing the situation by purchasing food at cost. In the same way, 
medical inspection examines the children and discovers exist- 
ing defects, but does not remedy those defects. It simply gives 
the parents an opportunity of knowing of existing conditions 
and it points out the remedy. Public-school cHnics and other 
forms of public treatment, of course, are rapidly entering the 
field of free treatment, but for the most part municipal clinics 
restrict free treatment to those in destitute circumstances. 



226 EDUCATIONAL HYGIENE 

In stating that the estabhshment of school feeding means 
the provision of opportunity to purchase wholesome food at 
cost, it would be misleading to overlook the fact that there 
will always be some children in the poorer sections of our 
great cities who are genuinely indigent and to whom meals 
must be furnished free, if they are to be furnished at all. 
There is nothing new about this situation, nor does it present 
any insurmountable difhculties. In every State and city where 
school text-books are purchased, there have been in force for 
many years different regulations for providing books free of 
cost to children unable to purchase them. The machinery for 
solving the same problem with respect to meals has been 
brought to a high state of perfection in several European coun- 
tries, though little has been done to meet it here. 

In America the school-limch movement which has had an 
astonishing development in the last five years is character- 
ized by the absence of the relief element. Although a large 
proportion of our school-children — lo per cent by conservative 
estimate, 25 per cent by more liberal interpretation — are suf- 
fering from malnutrition, the relief of this condition is not 
the primary aim of those advocating school meals. It is 
the conviction of American school men that, if the school is 
to assume responsibility, it must be because of educational 
considerations affecting 100 per cent of the children. This 
conviction was expressed again and again during the school 
feeding session at the Fourth International Congress on School 
Hygiene at Buffalo in August, 1913. 

Administration of Lunches in Elementary Schools. — 
Within the last five years the movement for extending the 
benefit of warm lunches served at cost to the children in the 
elementary schools has spread from five to ninety cities in 
twenty-eight States. While in the larger number of instances 
the work has been inaugurated by private organizations, such 
as women's clubs, home and school associations, and so forth, 
it has been always with the moral support of the school au- 
thorities and personal co-operation of members of the school 



SCHOOL FEEDING 227 

governments, in addition to financial help in the way of over- 
head charges and fuel. As in the case of the high schools, 
there is a distinct tendency to regard the work of the private 
organizations as preliminary demonstration of methods fea- 
sible for use by the school boards when they assume entire 
responsibility. According to Edward F. Brown, executive 
secretary of the New York School Lunch Committee, out of 
sixty cities thirty-five were serving meals under the jurisdic- 
tion of the school board. 

The essential features of the administration of the work 
in New York, which dates from 1908, are as follows: There is 
a committee of eighteen men and women, including school- 
board members, medical inspectors, social workers, and mem- 
bers of the faculty of Columbia University. The chairman is 
an experienced dietitian and social worker. The superin- 
tendent is a graduate dietitian with experience in teaching 
and dietetic social service in a hospital. The buying, and the 
engaging and direction of cooks and helpers, are in her hands. 
There are seventeen schools supplied with lunches at noon 
from four central kitchens. A year of experience with central 
kitchens has demonstrated their greater economy and effi- 
ciency as compared with separate kitchens. The only Kmit to 
centralization of kitchens is made by the necessity of provid- 
ing different menus for schools with attendance of different 
nationalities. Thus, separate provision is made for Italian^ 
Jewish, and Irish-American children. This is, however, dis- 
tinctly a problem of very large cities. 

The cooks are employed for the whole of each school day 
at a weekly wage of ten dollars. Under the superintendent 
are a corps of paid supervisors who are present two hours 
daily at each school to see to the preparation, selling, and dis- 
tribution of food. The actual serving of the food is done by 
pupil monitors who wear white aprons, caps, and gloves. 
These helpers receive their lunches free. 

Owing to the large numbers, and lack of special dining- 
room provision, the children eat their lunches standing at 



228 EDUCATIONAL HYGIENE 

long tables erected in the basement. Each child must pur- 
chase the main dish, a bowl of soup, before being allowed to 
get the penny extras served at a separate table. The kind 
of soup varies with the predominant nationality of the chil- 
dren. Examples of soups served in the American districts 
are: split pea, tripe, clam chowder, vegetable, Scotch broth, 
and macaroni. The food value varies from 74 to 148 calories. 
In the Jewish schools the food is heavier and, to avoid offend- 
ing the laws of kosher, entirely without meat, as: potato and 
barley, lentils and rice, lima beans and barley, rice and milk, 
Obergritz and potatoes, noodles and milk. The average num- 
ber of calories here is 190. In the Italian schools the special 
dishes are menestra, rice and tomato, beans and pasta, maca- 
roni, and rice with cheese and tomato. The average number of 
calories is 138. 

After the child has bought the soup he goes to the extra 
table, where he may purchase one or two other things at a 
penny apiece. Among the extras are: sandwiches with jam, 
egg, onion, lettuce, meat, bologna, and cheese; potato, cab- 
bage, tomato, or lentil salad; bread, chocolate, or rice pudding; 
cocoa; sweet chocolate squares; crackers, jelly cake; ice- 
cream; grapes, bananas sliced with milk, prunes, apple sauce, 
baked apple, apple sugared on stick. 

A child spending three cents at these tables gets from 
one-third to one-half of the total amount of food he needs 
during the day. 

Feeding in Open-Air Classes. — In classes for tuberculous, 
anemic, and convalescent children the lunches are as much a 
part of the treatment as the fresh air itself. The meals are 
more elaborate than is usual in the regular schools, and they 
are more frequent. The following menu is typical of the 
American practise: 

Breakfast: Cocoa, graham gems, butter, stewed prunes. 
Lunch: Stew of rice and mutton, or creamed codfish, mashed 
potato, bread and butter, milk, dates or figs. 

Supper: Milk, crackers and cream cheese, or preserved fruit. 



SCHOOL FEEDING 229 

These meals supplement the home meals. Counting in the 
average home meals, the children consume as much as 2,500 
calories, which would be far too high for normal children but 
not for these whose metabolism is overactive or deranged. 

Lunches in Rural Schools. — One reason that health con- 
ditions in rural schools have been so long neglected is because 
of the common idea that country children are naturally vigor- 
ous and healthy. ''This ought to be so but unfortunately is 
not," says Doctor Ernest Hoag, in a recent government re- 
port. He finds that, "in general, food is not as well prepared 
in the country as it is in the city; the available variety is 
smaller." Bad methods of ventilation and heating at home 
and at school, exposure to wet in the long walks to school, 
and overdressing in the house — all are inroads on the already 
badly nourished bodies. Investigations sl^ow that malnu- 
trition and its accompanying diseases are quite as frequent 
among country as among city children. Steps to remedy this 
condition are being taken in New Hampshire, Washington, 
Nebraska, South Dakota, Texas, and Minnesota; in the last 
two cases, under the direction of the State universities.^ 

The equipment necessary for the rural-school lunch need 
not be more elaborate than a top for the stove used for heat- 
ing, some pots, cups and spoons, and wash-basin and towels. 
The preparation and service can be done by the children in 
turn, and is an excellent adjunct to domestic-science lessons. 
Frequently a single warm dish, like soup or stew, or cocoa, is 
prepared to supplement the cold lunches brought from home. 
The two essentials are warmth and the presence of protein, 
as the lunches brought by the children, as well as their home 
diet, are apt to be overrich in starches and sugars.^ 

The Place of Nutrition in the School Hygiene Movement. 
— ^In 1867 M. Dupre, Commissioner of Education in France, 

* See report of Doctor Thos. D. Wood to National Education Association 
in February, 1915. 

2 See Andrew's " Education for the Home," part two, section two, bulletin 
611 of the U. S. Bureau of Education. 



230 EDUCATIONAL HYGIENE 

recommended to the local directors that they look into the 
health of their pupils and pay particular attention to their 
nutritional condition. This is the first time that an official 
concern for the nutrition of school-children was recorded in 
any country, although it does not mark the beginning of school 
feeding. School funds for the support of extra-academic 
activities, such as lunches and baths, were made general 
throughout France as a result of M. Dupre's suggestion, and 
in 1882 the "Caisses des Ecoles" were made compulsory along 
with general primary education. 

In 1872 a municipal law in Munich called for a kitchen 
and dining-room in all new school buildings. This was an 
official recognition of work which began as a relief measure in 
1792. In 1890 the school feeding movement in Germany re- 
ceived national recognition at a congress of vacation colony 
workers, where it was decided that the good results of sending 
children to the country in summer were more than counter- 
balanced by the evils of bad feeding throughout the year. 
In 1909 the National Society for People's Welfare, in a three 
days' conference, reported on work in half the German cities 
and in many rural districts. 

In England, between 1866 and 1905, largely through the 
efforts of teachers, no less than three hundred and sixty sepa- 
rate societies were organized for the rehef of acute distress re- 
sulting from hunger. The agitation over "physical deteriora- 
tion" in England, from 1902 to 1906, resulted in the discovery 
of malnutrition during the growing period as an important 
factor in the lowering of the national fitness. The first act of 
legislation to grow out of this agitation was the Provision of 
Meals Act, which gave the local educational authorities per- 
mission to install school restaurants as part of the regular 
school equipment. 

Malnutrition and Medical Inspection. — Recently there 
has been an increasing tendency to make the report on nu- 
trition of different children the basis of the entire medical- 
inspection report. This is because it has been demonstrated 



SCHOOL FEEDING 23 1 

again and again that the occurrence of disease and physical 
defects is largely conditioned by nutritional disturbances. 

In Paris medical inspectors have charge of the school 
canteens and are required to report on the nutrition of each 
child. They are further expected to follow up any child 
with impaired nutrition and to administer tonics and special 
care. 

In England, since 1907, compulsory medical inspection 
has included inspection of nutrition. Beginning with 1909, 
the chief medical officer of the National Board of Education 
has reported yearly on the nutrition of the children through- 
out the country and on the work of the school feeding centres. 
In Scotland the medical inspectors are required to see that 
children suffering from malnutrition are fed properly either 
by the school or by the parents. As a result of this system- 
atic work British school doctors are develcfping methods of 
technique and standards for judging malnutrition, which, on 
account of its complex and interwoven causes, is very difficult 
to estimate accurately. 

• The correlation of disease and malnutrition is every- 
where acknowledged. It has been worked out with scientific 
accuracy by Doctor Gastpar, of Stuttgart, who from 1906 to 
191 2 examined 65,000 children, making a thorough physical 
and medical examination, and then, dividing the children 
into five different nutritional groups, determined the propor- 
tion of disease and defects in each group.^ Briefly, his results 
were as follows: If the children in the best-nourished group, 
who numbered 13,229, were compared with those of the worst- 
nourished group, who numbered 15,807, it was found that 
among 100 well-nourished children there were j6 defects, 
whereas among 100 badly nourished children there were 18^ 
defects. The defects noted in this summary were: scoliosis, 
diseased glands, tuberculosis, heart-trouble, eye defects, ear 

^ For a preliminary report of this work see Zeitschrift fiir Schulgesund 
heitspflege, vol. 21, 1908, pp. 689-702. A detailed account of the entire in- 
vestigation is in preparation by the author of the present paper. 



232 EDUCATIONAL HYGIENE 

defects, albuminuria, and anemia. As the badly nourished 
all had anemia, it would be perhaps fairer to call anemia part 
of the nutritional condition rather than a separate defect. 
In this case there would be 8^ defects to every 100 badly nour- 
ished, anemic children instead of 18^ defects. 

The Classification of Nutrition. — Doctor Gastpar's method 
of classifying nutrition, which is known as the group method, 
is one of the most satisfactory yet devised for working use. 
It is briefly as follows: 

(i) There is first an individual examination of each child, 
in which measurements of height and weight are taken, and 
the state of nutrition determined by these and other factors, 
such as the state of the superficial circulation, the muscula- 
ture, skin tonicity, the condition of the mucous membrane, 
the expression of the eyes and the entire face, the roughness 
or smoothness of the hair, etc. At the same time other 
physical defects are noted that may bear upon nutrition, as 
the condition of the teeth, presence of adenoids, and particu- 
larly the presence or absence of anemia. 

(2) After these records have been made for each individual 
child, the children are then divided according to their ages. 
Then the children of each group are divided into those having 
anemia and those without it. These two groups are further 
subdivided until, in order of nutritional excellence, children 
in each age-group stand thus: {a) good; {h) fair; {c) fair with 
anemia; {d) poor; {e) poor with anemia. 

Experience in the application of this plan of classifica- 
tion has developed three general rules that are valid for ap- 
plication in any country. Briefly these rules are as follows: 

{a) Every child is examined separately in a room specially 
provided, where the light and temperature may be regulated. 

{h) One physician should make all the examinations for 
any given group of children. 

(c) The examining physician should be familiar with the 
racial peculiarities of growth, complexion, and coloring. 

This system involves time and care, but it insures a fair 
degree of accuracy in a subject not easy to define rigidly. 



SCHOOL FEEDING 233 

Some such scheme is absolutely necessary if experience is to 
be shared. This has been found specially valuable in record- 
keeping, and in finding the correlation between the state of 
nutrition and other physical conditions. 

Extent of Malnutrition among School-Children. — Until 
the practise of measuring nutrition by some such standard as 
that outlined above becomes more general, the present dis- 
crepancies in reports as to the exact extent of malnutrition 
among school-children will continue. In American cities no 
record of the nutrition of the entire school population has been 
made. In 1907 in New York the Committee on Physical 
Welfare of School- Children reported 13 per cent of 990 chil- 
dren, selected as typical of the whole city, to be suffering from 
malnutrition. A similar investigation of 10,090 children in 
Chicago in 1908 revealed 12 per cent badly nourished in all 
grades, the proportion decreasing from 15 per cent in the 
kindergarten to 6 per cent in the fifth grade and above. 
Wherever an attempt has been made to include all classes of 
children in the examinations, the percentages found suffering 
from acute malnutrition run from 10 to 15. Where only 
schools in the poorer districts are included, the percentages 
are far higher, and vary between 20 and 40. However, it 
must be remembered that children from the poorer districts 
far outnumber those in other schools, so that in point of figures 
the actual proportion of children suffering from malnutrition 
is probably nearer the second estimate. Doctor Thomas F. 
Wood, of Columbia, gives 25 per cent as the estimate for the 
school population of the whole country. 

"The longer a medical officer remains at school inspec- 
tion," remarks Doctor Hope, of Liverpool, in a report for 
191 2, "the more severe becomes his standard of nutrition, 
and the less readily does he pass a child as being well nour- 
ished." 

The truth of this is shown in the British reports, which 
from year to year show in the aggregate an increasing pro- 
portion of children grouped in the division of subnormally 
nourished. In 191 1 the average per cent reported was 11 



234 EDUCATIONAL HYGIENE 

for twenty- three communities; in 191 2 the average for twenty- 
seven cities was 13. The percentages from the different 
places varied from 3 to 30. 

In Stuttgart all the children were examined during six 
successive years, and classified according to the Gast^ar 
method described. Out of 65,000, 24 per cent fell in the 
group of ^'poorly nourished, with anemia,'' and only 20 per 
cent merited the grouping ''good." 

Malnutrition and Retardation. — ^In an address before the 
superintendents' section of the National Education Associa- 
tion in 1913, Superintendent Francis, of Los Angeles, gave as 
his opinion that a systematic provision of lunches in the 
schools would greatly reduce the cost of retardation. Princi- 
pals of Philadelphia schools have reported a substantial reduc- 
tion in afternoon truancy following the introduction of lunches. 
In 1894 lunches were introduced into Milan schools, where 
the average daily attendance was only 72 per cent of the en- 
rolment. This percentage increased after the introduction 
of the lunches to 94 per cent in 1905. A survey of the fac- 
tors making for non-promotion in Manchester, Connecticut, 
showed that of all the children who failed of promotion 25 per 
cent were suffering from malnutrition as opposed to 9 per 
cent among those promoted. 

Among mentally defective children, the proportion that 
are badly nourished is reported in Germany, England, and 
this country as being from 60 to 65 per cent. Lunches are 
being introduced into the special classes as a partial remedy 
for this condition. 

Planning of Dietaries. — The problems of school dietaries 
are: first, how to assure the children a lunch that shall satisfy 
the appetite, yield a fair proportion of the day's total ration, 
and make up for deficiencies of protein and fat found in the 
children's home diets; and, second, how to do all this while 
keeping the cost of food, preparation, and service within the 
ability of the children to pay. It must be remembered that 
the children's unit of payment is a cent. 



SCHOOL FEEDING 235 

This problem has been most satisfactorily solved in 
Bradford, England, where the meals are so well planned and 
conducted as to serve as a model not only for England but 
for us as well. There are seventeen dinner menus served in 
rotation, thus pro\dding the very necessary variety. A sam- 
ple dinner— meat pie, bread, green peas, gravy, and stewed 
fruit — ^yields a total fuel value of 894 calories, with 33 grams 
of tissue-building protein, 21 grams of fat, and 168 grams of 
starch and sugar. The cost of this meal to the city, including 
superintendence, preparation, and service, is three cents, 
and this is what the children pay. 

Experience in planning dietaries in different countries 
indicates that if the ration is in accordance with the needs of 
the average ten-year-old child weighing sixty pounds, this may 
be varied up and down quite easily for the older and younger 
children. The following is a practical basis for a plan of the 
whole day's needs: 

Protein 60 grams yielding 240 calories. 

Fats 40 grams yielding 360 calories. 

Carbohydrates 250 grams yielding 1,000 calories. 

Total 350 grams yielding 1,600 calories. 

The nutritive ratio of this dietary is i to 4.8. 

A study of the food values of the lunches in use in well- 
organized systems of school feeding in England, Switzerland, 
and Germany indicates that they furnish over one-half of the 
day's total ration — a little over one-half of the protein and 
not quite half of the fat. 

Money Value and Food Value. — If there is no school lunch 
provided, a large and growing proportion of the children buy 
their own lunches from venders at the door, and at near-by 
shops. The average value of one-cent lunches in Philadel- 
phia is 114 calories; children buying of the venders are able 
at best to get only 52 calories. Moreover, the street food is 
unclean and in many cases adulterated. Most school princi- 
pals and teachers have met with the serious and pernicious 



236 EDUCATIONAL HYGIENE 

influence of the cheap, adulterated candy and pastry sold at 
the inevitable parasitic "little candy store" near most schools. 

Present Extent of the School Feeding Movement. — • 
Lunches in the elementary schools form part of the regular 
educational provisions in practically aU the great countries 
of Europe. The movement has been made the subject of 
national legislation in France, Switzerland, Holland, Great 
Britain, Denmark, and Bavaria. It is national in scope, with 
direct support by the municipalities in Germany, Italy, 
Sweden, Norway, Finland, Austria, and Belgium. It has 
been started in Spain and Russia. 

In America lunches are commonly provided in the more 
progressive high schools. There are eighty-nine cities, in 
twenty-eight States, where lunches have been introduced in 
the elementary schools, and six States in which the move- 
ment for warm lunches in rural schools is under way. 

The Progressive party included school feeding in its 19 13 
platform for New York State, and Colonel Roosevelt has 
gone on record as favoring its incorporation in the State plat- 
forms generally. The Socialist party has long had school 
feeding as one of its immediate demands. The Massachusetts 
Legislature, early in 1913, passed an act providing that school 
systems might use funds for the support of lunches, subject 
to a referendum vote of the citizens. As the question is bound 
to come up for consideration in many State legislatures, the 
following act has been formulated on the basis of the best 
available experience to serve as a model for school systems 
contemplating such legislation: 

AN ACT TO PROTECT AND CONSERVE THE HEALTH 
OF SCHOOL-CHILDREN AND PROMOTE THEIR EF- 
FICIENCY BY PROVIDING MEALS AT COST IN THE 
PUBLIC SCHOOLS 

Section i. Any board of education in a school district may pro- 
vide for serving lunches and selling them to pupils attending the 
public schools at such prices as it may fix, not exceeding the cost of 
purchase and preparation and service of the food. 



SCHOOL FEEDING 237 

Sec. 2. Said board of education may employ a director of school 
lunches and other necessary assistants, and fix their rates of remunera- 
tion and draw up rules regulating the conduct of the lunches and the 
duties of the said employees. 

Sec. 3. Said board of education may appoint for the proper 
supervision of the school lunches a school-lunch committee which 
shall include in its membership the superintendent of schools, the 
chief medical inspector, and the director of school lunches or such 
other persons as the board may designate. 

Sec. 4. The expenses incurred under the provisions of this act 
shall be paid in the same manner as are the ordinary expenses for the 
support of public schools in the several school districts. 

Sec. 5. This act shall take effect immediately. 

Note. — See the writer's volume on the above subject. — Ed, 



CHAPTER XIV 
OPEN-AIR AND OPEN-WINDOW SCHOOLS 

The Problem. — The open-air school movement has gained 
a definite place . among the educational and ameKorating 
forces of the United States. Its development has been rapid, 
for it is based upon the experiences and knowledge acquired 
by an increasing number of social workers and social agencies 
over a considerable number of years. Settlement workers, 
agents for charitable organizations, tuberculosis agents, visit- 
ing nurses, juvenile court workers, infant welfare nurses, 
probation officers, church visitors, teachers and members of 
school boards, and a growing number of interested citizens 
have made the acquaintance of thousands of children living 
under our rapidly changing modern conditions. 

In increasing numbers these representatives have gone 
into the homes where poverty, sickness, delinquency, defect- 
iveness, and all manner of unfortunate circumstances have 
called them on their errands of neighborhness. They have 
come close to the homes of the poor and have acquired a 
first-hand knowledge of the handicaps under which less for- 
tunate people Hve. The bearing which untoward circum- 
stances have upon the Hves of children has impressed itself 
upon these workers as of paramount importance to the com- 
munity and the nation. The earher efforts were for measures 
of reHef. They endeavored to secure braces for crooked legs 
and crooked backs, to get hospital care for children who were 
iU, to acquire an imderstanding which would help them to get 
boys and girls out of trouble, or to secure them employment; 
or they went from the compulsory education department to 
force children into school; or from the courts to secure infor- 

238 



OPEN-AIR AND OPEN- WINDOW SCHOOLS 239 

nation about dependency and delinquency. These workers 
ound large numbers of children anemic, undersized, and ill 
)repared physically and mentally for the duties of life. They 
earned that thousands of them had dropped out of school at 
m early age and that the school experience had effected little 
)r no beneficial result. 

A procession of something like 100,000 children a year 
lies before the courts of the country, and the stories that 
lave been confided to the ear of the friendly judge by troubled 
:hildren and heart-broken parents have been challenging the 
.ttention of the nation. In following the trail of these little 
)eople into their homes, probation officers have become pos- 
essed of information and understanding which throws a 
;reat deal of fight on the reasons why children drop out of 
chool, as well as why they fail in their studies and cannot 
:eep up with the procession, why they get into trouble and 
Lo not fit into the industrial life of the community. From 
)urely palfiative and remedial work a widening number of 
aterested people have been challenging the situation and de- 
aanding a constructive programme. What the problem is for 
ine disease the following figures suggest. 

Influence of Medical Inspection. — Medical inspection in 
he pubfic schools has had a great bearing on the problem, 
n 191 1 over five hundred cities in the United States had a 
ystem of medical examination of school-children. Between 
tne-half and two-thirds of the children examined were found 
o have one or more physical defects sufficiently pronounced 
o need attention, many of them so serious as to handicap the 
:hild in his school work, and still others so marked as to make 
lis attendance at school dangerous to himself and to others. 

Discovering defects was the first step, but only the first. 
)0 far, less than one-half of the defects discovered have 
)een corrected. This work is becoming more efficient as 
chool nursing is provided, but there is still need for increasing 
he facilities for hospital, dispensary, and dental care, for 
ye defects, and for operations for adenoids and tonsils. 



240 EDUCATIONAL HYGIENE 

In a recent book, "The Prevention of Destitution/' Sid- 
ney Webb writes as follows of medical inspection and its re- 
sults in England: 

When we get the child to school, knowledge of its condition becomes 
forced upon the community. The first results of systematic medical 
inspection are bringing home to our minds what every teacher knows, 
namely, that a large proportion of the children are not in a fit state 
to have the public money spent on teaching them, because they are 
suffering to such an extent from neglect as to be unable to obtain full 
advantage of the instruction. What emerges from the cautious sum- 
maries of the chief medical officer of the Board of Education for 
England and Wales (Scotland and Ireland being at least as bad) is 
that out of all the 6,000,000 children in the elementary schools about 
10 per cent suffer from serious defects in vision; from 3 to 5 per cent 
suffer from defective hearing; i to 3 per cent from suppurating ears; 
8 per cent have adenoids or enlarged tonsils of sufficient degree to 
obstruct the nose or throat and to require surgical treatment; 20 to 
40 per cent suffer from extensive and injurious decay of the teeth; 40 
per cent have unclean heads; about i per cent suffer from ringworm; 
I per cent are affected with tuberculosis of readily recognizable form; 
and >^ to 2 per cent are afflicted with heart-disease. 

Infant Welfare Organizations. — One of the newer and most 
fundamental movements has gone straight to the heart of 
the problem of physical welfare of children, and that is 
the work of the infant welfare organizations. These people 
have found that we have about 250,000 baby funerals in this 
country annually of children in their first year. This means 
about 150 out of every 1,000 babies. This is better than the 
figure in Russia, where it is 263, but it is a sad comparison 
with New Zealand, where it is less than 75. These were our 
figures as given by the American Association for the Preven- 
tion and Study of Infant Mortality in 191 1. 

It has been stated that the mortality among infants is one 
of the best indexes of the community's concern for human 
life. The story of such mortality as this is not fully told in 
the frequent use of the white hearse, for many children sur- 
vive only to emerge from the dangers of babyland with im- 



OPEN-AIR AND OPEN-WINDOW SCHOOLS 



241 



paired physique and weakened resistance. All children must 
be babies first, and the candidates for the schools must pass 
through the ignorance and dangers of babyland; and these 
figures show that being a baby is about the most hazardous 
pursuit in the world. 



TABLE 1 
Death-Rate from Tuberculosis 



AGE PERIOD 


death-rate from tuberculosis (all forms) 
per 100,000 population of the states in- 
cluded in the registration area in igoo.' 
(94,205 deaths) 


PER CENT WHICH 
RATE IN I9II 
REPRESENTS OF 


I9II 


1901 


THAT IN 1 90 1 


Both 

sexes 


Males 


Fe- 
males 


Both 

sexes 


Males 


Fe- 
males 


Both 

sexes 


Males 


Fe- 
males 


All ages: 

Crude rate 

Corrected rate'. . . 

Under 5 years 

r 5 to 9 years 

< 10 to 14 years .... 

( 15 to 19 years 

20 to 24 years 

25 to 34 years. ..... 

35 to 44 years 

45 to 54 years 

55 to 64 years 

65 to 74 years 

75 years and over. . . 

25 years and over: 

Crude rate 

Corrected rate^, . . 


158.9 
150-1 


179.4 
167.0 


138.0 

134-4 


188.8 
181. 3 


199-9 
189.3 


I77%6 
173-8 


84 
83 


90 

88 


78 
77 


126.7 
3I-I 
35-6 
115-3 
188.0 
217.8 
228.4 
191. 
193-6 
194-3 
158.6 

209.3 
206.5 


133-3 
31-4 
27.6 

99-9 
190.9 
230.4 
278.5 
253-5 
253-0 
229.9 

177. 1 

249.1 
248.8 


120.0 
30.9 
43-7 
130.4 
185.2 
204.6 

175-5 
124.6 

133-4 
160.6 

143 -I 

168. 1 
168.6 


138.2 

31-0 

39.4 
144.2 

251-9 
282.6 

254-7 
208.8 
220.2 

253.5 
241.0 

251.0 
249.1 


147-7 
31.6 
26.5 

118. 1 

247-3 
287.0 

285.9 
256.5 
267.3 
284.3 
256.3 

277.7 
277.6 


128.6 
30.4 
52.4 
169. 1 
256.2 
278.2 
221 .6 
159-0 
173-9 
224.3 
227.5 

223.7 
223.6 


92 
100 
90 
80 
75 
77 
90 

91 

88 

77 
66 

83 
83 


90 

99 

104 

85 
77 
80 

97 
99 
95 
81 

69 

90 
90 


93 
102 

83 
77 
72 
74 
79 
78 
77 
72 
63 

75 
75 



iFrom 191 1 U. S. Mortality Statistics. 

2 Includes Connecticut, the District of Columbia, Indiana, Maine, Massachusetts, 
Michigan, New Hampshire, New Jersey, New York, Rhode Island, and Vermont. Regis- 
tration area included 63.1 per cent of the population. 

3 Corrected on basis of standard million of England and Wales, 1901. 

Note. — ^The colvmin for "both sexes" third from the right side means, for example, 
that the crude rate from tuberculosis for all ages was only 84 per cent of what it was ia 
1 901, and that the rate for children from S to 9 years was unchanged. 



Our schools, then, are constantly recruited by an army 
of little people of weakened resistance, ill nourished, im- 
properly cared for, and poor material to be wrought upon by 
the school regime. The school process has gone on without 



242 EDUCATIONAL HYGIENE 

that consciousness of individual needs, that discriminating 
concern for each child, to which it would seem that the most 
handicapped, at least, are entitled. The general tuberculosis 
crusade with its carefully worked out programmes has been 
one of the most pronounced factors in setting the commimity 
at work. 

The open-air school is one of the pieces of social ma- 
chinery that have come into existence because of these ex- 
periences and the convictions which have grown out of them. 

Open-Air Schools at Home and Abroad. — ^The open-air 
school, in the modern acceptance of the term, was started in 
Charlottenburg in 1904 as a rest-recovery school. It was a 
fresh-air camp for debilitated children, located in a beauti- 
ful pine forest just outside Charlottenburg, a suburb of Berlin. 

The German people were first in the field in sanatorium 
treatment for tuberculosis. They soon discovered that if de- 
bilitated children were sent to the sanatorium, while they 
gained in health they lost in educational progress. On the 
other hand, if they were kept in the public schools they de- 
teriorated in health. 

The now famous Waldschule provided the missing link 
and became a real educational experiment, but with the 
teaching always secondary to health. New methods of in- 
struction were devised, and a rich and varied programme was 
worked out for the children. Their school day included, be- 
sides the ordinary recitations, gardening, walks in the forest, 
nature-study work, five feedings a day, sim-bath, gymnastics 
in the open air, and a rest period from one to two hours in 
length. 

In his report for 191 2 the chief medical officer of the Board 
of Education in London makes the following statement: 

Open-air education was practised by the Greeks and Romans, was 
commended by the educationalists of the seventeenth and eighteenth 
centuries — Locke, Rousseau, and Pestalozzi — and has been attempted 
in various forms since 1876, when Bion, of Zurich, initiated the chil- 
dren's country-holiday movement. The growing of the towns, the in- 



OPEN-AIR AND OPEN-WINDOW SCHOOLS 243 

crease of social effort and experiment, and the movement for the pre- 
vention and treatment of tuberculosis have, no doubt, been factors 
in the recent progress of the open-air school movement. In 1907 the 
London County Council established a school of this kind at Bostall 
Wood, and there are now about a dozen schools in different parts of 
the country. 

France, Switzerland, Italy, and Hungary have open-air 
schools with similar curricula and management. In general, 
the tendency in Europe is to construct open-air schools in 
the country on a plan which permits giving the children day 
and night care until their recovery is assured. 

The first open-air school in the United States was estab- 
lished in 1908 at Providence, Rhode Island. There are at 
the time of writing more than 500 open-air schools and open- 
window classes in the United States. Passijig through the 
makeshift period, when ferry-boats, piazzas, and tents were 
used for schoolrooms, the open-air school movement has pro- 
gressed to the stage where school architects are incorporating 
specially designed rooms for such work in the plans of their 
most recent buildings. 

Principles and Methods of Open-Air Schools. — ^The 
method and aim of the open-air school is to furnish the child 
with a programme suited to his needs. It is not merely school 
in the open air; it comprises a way of life and a system both 
of education and medical treatment. The children are ad- 
mitted to such schools through a careful medical examina- 
tion, the aim of which is to secure accurate knowledge of the 
child's physical condition. This information furnishes the 
guide for such medical treatment and correction of physical 
defects as are necessary to estabhsh the efficiency of the pupil. 
A daily inspection by the physician in charge gives opportu- 
nity to check any temporary indisposition and to study the 
effect of the modified regime upon the individual child. 

In most open-air schools temperature and pulse are re- 
corded at least once daily and the children are weighed at 
stated intervals. A daily cold shower-bath or a weekly warm 



244 EDUCATIONAL HYGIENE 

cleansing bath is ordinarily given at the school. Meals are 
served from once to three times during the day. The physi- 
cian plans the diet list and often orders special diets for badly 
undernourished children. 

A rest period usually follows the noon meal. All the 
children recline on canvas cots or steamer-chairs for a period 
varying from forty-five minutes to two hours. Ordinarily, 
two- thirds sleep regularly; at any rate, they rest. Where a 
child does not waken at the end of the period and has seemed 
to be in special need of rest, the teacher may permit him to 
remain asleep until the close of the school day. 

The nursing supervision extends from the school into the 
home. The majority of open-air schools in this country are 
in the congested portions of cities, where the daily lives and 
habits of children are not so well or so carefully regulated as 
they would be in smaller communities. The children go to 
bed late and usually sleep with other persons in poorly ven- 
tilated rooms. 

The 19 1 2 report of the London Board of Education points 
out ''that it would be diihcult to exaggerate the physical 
and mental injury its children suffer from a lack of sufficient 
sleep and genuine rest. Large numbers of children who re- 
quire for physical health at least ten hours' rest at night are, 
in fact, obtaining much less than that amount; and this one 
condition is responsible for not a little of their physical un- 
fitness and mental dulness. Further, there are various mal- 
adies from which they suffer and which are being revealed by 
medical inspection, which call for the therapeutic remedy of 
rest." 

The teacher in a Boston open-air school says that the open- 
air school must, in an unusual sense, be mother and school 
both. "It is found," she says, ''that many of our pupils are 
up until all hours of the night and out again early in the morn- 
ing. They are improperly clothed, improperly fed, never 
bathed, and live in rooms that are never ventilated and are 
occupied by three, four, and five others. Often they come to 



OPEN-AIR AND OPEN-WINDOW SCHOOLS 245 

school unfed, not always because there is no food, but because 
there is no regular living and food has not happened to come 
their way. If it does, it is more than probably not the right 
kind. It may have been soggy, half-baked bread with a little 
pepper on it to 'keep them warm.' '* 

The nurse who cares for the children at the school goes 
with them to their homes and tries to enlist the co-operation 
of the parents in giving the child better food, better ven- 
tilation, and better sleeping-quarters. In the Chicago open- 
air schools it was found necessary to make a ruling that any 
child who persisted in remaining up after eight o'clock at night, 
without good reason, should be excluded from the school. 

The influence of the nurse has often accomplished the 
removal of a whole family from insanitary quarters where 
privacy and decency were well-nigh impossible to homes 
which corresponded more nearly with hygienic standards. 
The nurse accompanies the children to the dispensaries, in- 
vestigates at once in case of absence from the open-air school, 
and, in general, watches over the physical well-being not only 
of the pupil himself but of his family. 

Structure and Equipment. — The distinctly open-air school 
is one where the air is practically the equivalent of outdoor 
air. Windows and wind-breaks are so placed as to control 
the entrance of storm and wind. 

The first open-air schools in the United States utilized 
existing buildings by modifying the window structure, or 
erected cheap temporary shacks to serve as their experiment 
stations. Thus Providence established the first school in an 
abandoned schoolhouse, Boston on the roof of a park re- 
fectory, Pittsburg on a hospital balcony. New York on dis- 
used ferry-boats, while Chicago built asbestos shacks on the 
roofs of convenient buildings in the tenement districts. 

Climate and local conditions determine absolutely the type 
of building best suited for open-air work in any particular 
community. The rapid increase in the number of open-air 
schools has led several cities to make permanent provision in 



246 EDUCATIONAL HYGIENE 

their regular school system for open-air work. Boston, New 
York, and Oakland, California, are among the cities which 
have definitely decided to incorporate fresh-air rooms in all 
new buildings to be erected. 

This new development in schoolhouse architecture is 
more marked as yet in those Western States whose climates 
permit of open windows and no heat during a good part of 
the school year. 

In California practically all the new buildings are being 
erected in such a way that they can be thrown entirely open 
on at least one side. In the Eastern cities, where ground is at 
a premium and transportation is poor, more roofs have been 
pressed into service. Cleveland has a magnificent new build- 
ing, the roof of which was specially planned to accommodate 
four open-air schools. The children are taken to the roof by 
an electric elevator, and play-space, recitation-rooms, rest- 
rooms, kitchen, and dining-room are all provided on the roof. 
Detroit will erect two such buildings within a year. Many 
cities are modifying the style of windows in their school- 
houses, substituting for the old-style windows hinged windows, 
to swing either in or up and to occupy a larger portion of the 
wall space. 

Another recent suggestion is that of substituting open 
verandas for the long, dark hallways of the ordinary school- 
house. The architect claims that such a building would be 
much less expensive to construct and far safer in case of fire. 
It would permit of long windows opening on the verandas, 
which could be thrown open in case of favorable weather. 

Portable buildings are used in the yards of schoolhouses 
in many places. In Europe the Doecker portables are used 
very largely for open-air work and were awarded a gold medal 
at the Third International Congress on School Hygiene. 

The open-window room is a room in the ordinary school 
building in which an attempt is made to approximate outside 
conditions by regulating the amount of heat supplied and by 
keeping the windows constantly open. Here, also, wind- 



OPEN-AIR AND OPEN- WINDOW SCHOOLS 247 

shields of various devices are used to keep the air from blow- 
ing directly on the children. The temperature in cold weather 
averages about fifty-five degrees in such rooms. The contrast 
between the freshness and purity of the air in the open rooms 
and that in other rooms of the same building with artificial 
ventilation in use is extremely marked. The difference in 
temperature is made up by extra feeding and by extra clothes. 
There is always the need of careful medical supervision, and 
it would be a hardship to the children to subject them to the 
lower temperature without adequate provision for clothing. 

In the schools of Chicago children are furnished with 
lumbermen's boots or other foot-protection, and with sweaters 
or Eskimo suits for schoolroom use. There is always need 
that either the physician or teacher, especially the latter, 
shall see to it that the children put on wraps when the tem- 
perature is low, as they will often themselvesMeclare they are 
warm enough and fail to put on the additional garments. 

The individual equipment for a child in an open-air 
school includes boots, Eskimo suit or other warm, loose gar- 
ments with gloves or mittens, sleeping-bag, blankets, cot, 
tooth-brush, paper napkins, and thermometer. 

The school equipment must include, in addition to desks, 
blackboards, and the ordinary furnishings of the schoolroom, 
provision for serving meals and some kind of locker in which the 
suits and other articles of individual equipment may be kept. 

Results of Treatment. — So uniform has been the record 
of the mental and physical improvement of the children under 
the open-air regime that detailed statements of gains seem 
hardly necessary. We expect increases in weight, height, 
chest-expansion, and muscular power, improved nutrition, 
better color, and more erect carriage; and we know that with 
these physical gains will come greater alertness and more 
power of concentration, consequently better scholarship and 
more regular attendance. 

It is of special interest, however, to compare these records 
with those of children in the public schools. Such a comparison 



248 EDUCATIONAL HYGIENE 

was made during the school year 191 2-13 by Doctor Harold 
Brown Keyes between the children in the outdoor classes of 
the Horace Mann School, Columbia University, and cor- 
responding grades indoors in the same school. These are all 
supposedly normal children from good homes. 

The hemoglobin tests given at a six months' interval 
showed that, although both indoor and outdoor children lost 
in hemoglobin, the outdoor children lost only about one-ninth 
as much as the indoor. A comparison between the past at- 
tendance-records of fourteen fourth-grade children in the open- 
air school and indoors gave a better record of 4.3 per cent in 
favor of the outdoor schools. The children were two years 
older, however, than when the first record was made. 

A record of contagious diseases kept during the year 
showed that 12.5 per cent of the outdoor children had con- 
tagious disease to 17.9 per cent of indoor children. No con- 
tagious disease "went through" an outdoor room, as happened 
in one of the indoor rooms. There was far less absence for 
illness. 

In the mental tests, to quote only two examples, the third- 
grade open-air school children tested in formal English showed 
a 20 per cent improvement from December to May, while the 
indoor gained 13 per cent; the outdoor fourth grade gained 7 
per cent and the indoor fourth grade lost 3 per cent. In arith- 
metic, the third-grade open-air improved 20 per cent and the 
indoor 6 per cent, while the fourth grade made 41 per cent in 
the open air and 35 per cent indoors. 

The supervising physician of the Bradford, England, open- 
air school reports that the results for 191 2 showed remarkable 
gains in weight and health and increase of the percentage of 
hemoglobin in the blood. The average attendance for the 
year was 138.3 and the average duration of attendance rather 
more than five months. The average gain in weight was 
about four and one-half pounds. There was an increase of 
21.5 hemoglobin, and the chest-measurements showed an 
average increase of 1.12 inches. 



OPEN-AIR AND OPEN- WINDOW SCHOOLS 249 

The school medical officer at Halifax, England, draws 
certain general conclusions from his additional experience in 
the treatment of debilitated children. He states: 

(i) Cases of malnutrition with its attendant anemia, debility, etc., 
give uniformly good results under open-air school treatment, unless 
counteracted by home influences at night and week-ends. 

(2) Simple tubercular glands are quickly influenced. In the 
three cases reported "fair" or "worse," there were lung signs suffi- 
cient to account for the poor progress. 

(3) Heart cases if compensated, and enfeebled circulation, respond 
well. 

(4) Early manifest phthisis responds better than the latent or 
suspected type characterized above as pretubercular. This confirms 
our previous experience that a child saturated with tuberculous poison, 
without manifest signs, is a more difficult problem than the child with 
an open lesion. 

Should the children themselves be asked now the open-air 
school has affected them, they would almost without exception 
give unconscious testimony to the change which has been 
wrought in their mental attitude as well as in their physical 
condition. 

A little Italian boy in Boston, writing to his teacher in 
an English exercise, says: '^I come to school to learn. When 
I went through the rooms I am going to college, and after I 
went to college I am going to work in an office, and I thank 
you, Miss Dally, for making me smart, and I thank you for 
the malted milk, and I thank you for bringing me into the 
yard." 

An Open-Air Letter. — ^Another child in a Chicago open-air 
school wrote the following autobiography for The Open Air 
Smile, a little paper which is published monthly by the chil- 
dren attending the Elizabeth McCormick open-air schools: 

I was born in Russia, May 25, 1899. I can speak the Russian 
language and my nationality is Jewish. I was born in a little gray 
house in a little country town near the city of Kiev. 

When I was two years old my downfall began. First I fell sick 



250^ EDUCATIONAL HYGIENE 

and had the scarlet fever, and as soon as I was cured of that I caught 
diphtheria, and after I was cured of that I caught pneumonia. I 
stayed in bed for a year and I never got out of bed for that long time. 
I believe that all of these sicknesses left me tubercular. 

When I was six years old I came to America and to the city of 
Chicago. Everybody had told us in Russia that gold was lying every- 
where in the streets. I started to go to school at the Garfield school. 
Later we moved to a different street, so I took a transfer to the Lang- 
land school, and later on we moved again, and then I came to the 
Goodrich school, which I attended a couple of years. When I was 
finally in the seventh grade I was sent out to the Winfield Tuberculosis 
camp. I stayed there six months because I was charged v/ith having 
tuberculosis. Those six months passed away so quickly that it seemed 
to me like six weeks. I think it was the happiest time of my life stay- 
ing out there. 

Everybody was very kind and nice to me out there. They were 
very sorry when I went home, but when I finally came back from 
Winfield I was a changed fellow. Hardly anybody recognized me, 
because I was not the sick little fellow that I was when I went to Win- 
field, but a big, strong and healthy boy with cheeks like roses. Later 
on I was put in the Foster Open Window Room, where I am now in 
the eighth grade. 

Other items which show the restilts of the open-air school 
upon the child's attitude follow: 

When I was on the street car and was going to open the window 
the conductor said that I should keep the window closed. I told him 
that I was not used to closed windows. There was a lady sitting right 
next to me and she said that I was right. I did not open the window, 
but I went out where the motorman stands. I told him that and he 
laughed about the conductor. I asked him to open the window and 
he opened it. When I got home I told my mother and she said I was 
right. 

We almost lost two of our classmates this month. Harry Row's 
and Olga Zemit's fathers moved out of the district. All their brothers 
and sisters got transfers and are going to another school, but Olga 
and Harry take the car and come to our school every day. They said 
their mothers did not want them to leave our room because they were 
so much better than they used to be, and they were afraid they would 
not keep so well if they left us. 



OPEN-AIR AND OPEN- WINDOW SCHOOLS 251 

When I told my mother that we did not have any school for a 
whole week, she said, "I bet you will be two pounds less." When I 
got back to school and was weighed I was two pounds and a quarter 
less, so my mother was right. 

Effect on Teachers. — ^The reflex action of the outdoor life 
on the teacher can best be stated by those who have experi- 
enced it. ^' Those who have tried the outdoor work have 
been capable of more prolonged labor with far less fatigue," 
says the teacher of the first Boston open-air school. ''The 
work is heavier in an open-air class but I feel much more 
able to accompHsh it. After the day's work I now return 
home fresh and do not suffer from the usual headache and 
dryness of throat that follow teaching in the ordinary room," 
comes from New York; while an Elizabeth McCormick open- 
air-school teacher testifies that backache, ^xtreme fatigue, 
and nervousness have been overcome by the fresh air and 
sunshine on the roof. 

A district supervisor of the Chicago public schools reports 
to the board of education in regard to the open-air school 
teachers who are under her direct supervision as follows: 

When a teacher has twenty-five pupils who represent anywhere 
from two to seven different grades; when her recitations are inter- 
rupted by the call of a physician or nurse; when entire classes are put 
to rest for the day at the menacing demand of a "rise in temperature," 
she is obliged to meet the situation with cleverness and calm. How is 
she enabled to do this ? Not alone because she is breathing the purest 
air this smoky city can bestow, but because her small number of 
pupils, her comprehensive knowledge of their physical, mental, and 
home conditions, her interest in their all-around development, have 
brought her into a close human relationship with them not often 
attainable under the conditions of the ordinary schoolroom. She is 
their intimate friend as well as their teacher. 

The teachers pass on the enthusiasm for fresh air to their 
fellow workers, and gradually the impression permeates the 
teaching force that it is better to have the windows open and 
the room temperature lower. Engineers and janitors fall into 



252 EDUCATIONAL HYGIENE 

line, and presently the parents discover that school ventila- 
tion is a very live issue. 

In December, 19 13, the superintendent of schools in 
Middletown, Conn., issued what is supposed to be the first 
sweeping order to turn practically every school in the town 
into an open-window school. The parents were notified that 
beginning on a certain date the temperature in all school- 
rooms would be lowered and the windows kept open; that 
care would be taken to keep draughts from blowing directly 
upon the children and any child who brought a written ex- 
cuse from the family physician would be placed in a heated 
room. Parents unable to provide extra clothing for their 
children were to be helped by the board of education. 

The influence which the open-air schools are exerting 
upon schoolhouse architecture has been indicated under the 
section on "Construction and Equipment." 

With our increased knowledge of tuberculosis and the 
best means of avoiding it, and our realization of the large 
number of physically subnormal children in addition to those 
definitely tuberculous who would be benefited by the open- 
air school regime, the open-air school question is assuming 
large proportions. 

The Pennsylvania school code already excludes from the 
public schools any person having tuberculosis of the lungs, 
whether it be teacher, pupil, janitor, or other employee. 
The result in Pennsylvania has been to stimulate the establish- 
ment of a large number of open-air schools which have been 
uniformly successful in caring for the excluded children. 

In England the tuberculosis regulations of 191 2 make 
the notification of all forms of tuberculosis compulsory. 
This means that English cities can now for the first time 
tell definitely how many tuberculous children they have for 
whom some kind of provision must be made in the public 
schools. The estimate of the examining medical officer of 
London is that at least 10 per cent, including the anemics and 
the malnourished, are suitable subjects for open-air schools. 



OPEN-AIR AND OPEN-WINDOW SCHOOLS 253 

Essentials of a Community Programme. — Most commu- 
nities are becoming conscious of the needs of their school- 
children, and are endeavoring to create forces to meet these 
conditions. In The School Review for December, 19 13, Fred- 
erick L. Hoffman estimates that in 1913 12,229 deaths among 
children and young persons of school age occurred in the 
United States from tuberculosis. 

First. In the schools of every large city will be found 
certain children who have open, active tuberculosis, and who 
need sanatorium care where they can be given continuous 
treatment until the process is arrested. A part of each com- 
munity's child-welfare programme should include a sana- 
torium built, equipped, and operated to serve the peculiar 
needs of children. 

Second. There will be other children wjio should have 
the kind of care that is afforded in the hospital school, where 
the health of the child is the paramount issue, and the aca- 
demic work is absolutely secondary and tempered carefully 
to the child's physical abilities. Boston has such a school. 
It is run under the auspices of hospital authorities and in 
connection with a hospital sanatorium. "Such a place is 
for children manifestly tuberculous who ought not to go to 
the regular public schools, or even open-air rooms, and yet 
who are not sick enough to require bed treatment in the 
hospital sanatorium." Some of the children go only for the 
day, others stay the whole week, returning Saturdays. There 
are many children of this type in the schools of a large city. 

Third. There- should be open-air schools where children 
may go during the regular school hours daily. These schools 
should have outdoor conditions of air, and the children should 
be selected and supervised in accordance with the medical and 
nursing regime described before. Feeding, rest, and careful 
co-operation with the home should be features of this pro- 
gramme. This school will deal with the anemic child, with 
contact cases, and with children who are predisposed to tu- 
berculosis. 



254 EDUCATIONAL HYGIENE 

Fourth. The open-window room. Some of the most 
advanced cities are planning to have such a room in every 
school. To these rooms the children who need special con- 
sideration and care may be admitted. The temperature in 
such rooms is more easily modified, but the air can be kept 
fresh and invigorating by keeping the windows open, care 
being taken not to have the wind blow directly on the chil- 
dren, and to see that additional wraps are provided and that 
the children wear these wraps when they need them. 

It seems to be necessary in our educational processes 
to learn our most vital lessons from defective, delinquent, 
and physically subnormal children. Not many years ago 
the only place to secure manual training was in the reform- 
atories or correctional institutions. Madame Montessori 
and other educators have taken some of their most vital 
lessons from backward children. The best attendance in 
the Chicago schools during a recent term was in a room 
fitted up with manual-training and other similar devices and 
to which a lot of truant boys were assigned. 

Any commimity that will provide along these lines for its 
special groups of children will in the process have learned 
that such facilities are also good for normal children. The 
ultimate aim and goal of the open-air school movement is 
nothing short of right conditions of sanitation, hygiene, and 
school opportunity for the 20,000,000 boys and girls in the 
schools of the United States. Children should not neces- 
sarily be sick or backward or wayward to enjoy privileges 
and processes which in a peculiar way appeal to child nature 
and satisfy its intrinsic demands. 

Note. — See the writer's volume on "Open Air Crusaders." — ^Ed. 



II. SCHOOL SANITATION 

CHAPTER XV 
RURAL SCHOOL SANITATION 

The Need for Rural School Sanitation. — In this chapter^ 
only those features of school sanitation in which the rural 
problem differs from the general problem will be discussed. 
The difference lies principally in the arrangements and equip- 
ment adopted to make the school sanitary, as different means 
must be employed in the country from those employed in the 
city. Especially is this true in the one-teacher schools. Also, 
rural school sanitation is concerned with mote than urban 
school sanitation on account of its wider field of influence. 
The following principal reasons why the rural school building 
and grounds should be made sanitary may well be reviewed: 

First: So that they may be as attractive as possible to the 
pupils. 

Second: So that the health of the school-children and 
teachers may not be endangered. 

Third: So that the health of the community may not be 
endangered through diseases disseminated from the school by 
the children, or by other agencies such as the wind, rain, and 
animals, particularly insects. 

Fourth: So that the children may learn directly what 
sanitation means, and may acquire sanitary habits in the 
school for use at home, both while pupils in school and in 
their lives after the school-days are over. 

Fifth: As a demonstration of sanitation and of sanitary 
equipment to the citizens of the school district. 

All of these factors should be borne in mind in planning 
the rural school. Consideration is seldom given to the first, 
*See also cliapter X on "Rural School-Health Administration." 

255 



256 EDUCATIONAL HYGIENE 

since it is generally supposed that children take little notice 
of the sanitary arrangements of the school plant. This is 
true only to a certain extent. The insanitary outhouse is 
very repulsive to the children, especially to those who come 
from homes where clean, comfortable ones are provided. They 
are much more repulsive at an early age than later when the 
child has grown accustomed to the objectionable conditions. 
President John R. Kirke, of the Kirksville, Missouri, Normal 
School, tells of a boy who wanted to attend a ''model one- 
teacher rural school" maintained on the normal campus as a 
demonstration and training school for students preparing for 
rural teaching. Children are brought in to the school each 
day in one large transportation wagon. This boy, nine years 
old, lived three miles from the model school and not on the 
wagon route. He was willing to tramp in to the school each 
day if allowed to attend, giving as his reason for not liking 
the district school near his home, "They haven't got any 
modern toilets out there." 

The second reason is the one usually given for having a san- 
itary plant, but it is of no more importance than some of the 
others. Much sickness on the part of school-children comes 
directly from the school — ^poor lighting, bad ventilation, over 
or under heating, being some of the causes. Many dis- 
eases are contracted from other children either directly or 
indirectly. Insanitary outhouses are often the cause of the 
pollution of the water supply of neighboring farms or the 
source of disease spread about by flies and other insects. 
Only recently typhoid fever, which caused the death of two 
young women in the same family in Kentucky, was found to 
have resulted from the use of spring water contaminated from 
a school privy located a short distance away. 

The fourth and fifth reasons seem to me to be very impor- 
tant. If the child, unaccustomed to sanitary practises at 
home, acquires sanitary habits at the school and becomes 
familiar with sanitary equipment, he will probably do what 
he can to provide himself with similar improvements at his 



RURAL SCHOOL SANITATION 257 

parents' home and later at his own home. In this way the 
school assists in the great campaign for improved sanitation 
now being conducted throughout the country. It assists 
not only the families represented in the school but also the 
entire community, for its sanitary equipment is to the com- 
munity an actual demonstration. In many parts of the 
country little headway has yet been made in securing the 
adoption of faciHties for making the farm and farm home 
sanitary. Several diseases that have almost entirely disap- 
peared from cities with proper sewage-disposal systems are 
still rampant in rural districts. Hookworm, with which 
probably one million persons in the United States are now 
suffering, is confined wholly to rural territory, and typhoid, 
while not wholly a rural disease, is more prevalent in the 
country than in the city. When occurring in the city it is 
found usually to have come from contaminated food suppKes, 
or milk or water brought in from the country. It is there- 
fore desirable that country life be made more sanitary, not 
only for the benefit of those living in the country but also 
for city people as well. It cannot be accomplished wholly 
by preaching the dangers of disease, but must be accom- 
panied by actual demonstrations of sanitary equipment. 
This it is the privilege and duty of the school to do. A sani- 
tarily equipped farmhouse is a demonstration only to the 
few who have access to the house; the sanitarily equipped 
school is a demonstration to all, because all may visit the 
school. 

It has been the experience of schools where such improve- 
ments have been installed that many persons have come to 
inspect the equipment. A few years ago the Farragut School, 
at Concord, Tennessee, installed a water system, water being 
obtained from a neighboring spring. Sanitary closets, show- 
er-baths, and drinking-fountains were placed in the school. 
Few farmers of the surrounding country had ever seen such 
provisions before their installation in the school, but there 
are very few now who have not seen the school equipment i 



258 EDUCATIONAL HYGIENE 

and many, since seeing it, have installed similar equipment in 
their own homes. When the principal of a small consolidated 
school in a backward community in northern Louisiana had 
his schoolboys make screens for the schoolhouse windows, 
and for the windows of his house, which was located on the 
school grounds, he thereby introduced screens into the com- 
munity. None had been used before. The neighbors of the 
school saw the benefits immediately, and the windows and 
doors of probably every house in the territory served by the 
school are now screened.^ 

In selecting equipment for the rural school it is necessary 
to bear in mind that it is to serve a wider sphere of useful- 
ness than that of making the school sanitary. Its adaptabil- 
ity to the home should receive strong consideration. When 
equipment suitable to the home as well as to the school can 
be obtained, it should in general be selected in preference to 
equipment suitable for school use only. Equipment should 
be obtained, whenever possible, within the reach, so far as the 
cost is concerned, of the average family of the community. 

The Sanitary Rural School Plant. — In locating, building, 
and equipping the rural school the following points relative 
to sanitation should be observed: 

(i) The yard should be sufficiently dry to be used as a 
playground at all times except on unusually wet days. 

(2) The building must be well enough built to be comfort- 
able on cold, windy, or wet days. 

(3) The building must be properly heated, ventilated, and 
lighted, and the interior decorated in the colors most restful 
to the eyes. 

(4) Proper arrangements must be made for cleaning the 
building. 

(5) A supply of pure drinking water must be available, 
also suitable arrangements for washing hands and faces. 

* See bulletin on " Consolidation of Rural Schools and Transportation of 
Pupils at Public Expense," by the writer. (Bureau of Education, Washington, 
D. C.) 



RUIIAL SCHOOL SANITATION 259 

(6) The grounds must be free from filth of any sort, es- 
pecially from decaying food material or animal refuse. 

(7) Clean, sanitary toilets must be provided. 

The School Lot. — The school, if possible, should be lo- 
cated on a site naturally drained, so that artificial drainage is 
unnecessary. If such a lot cannot be secured, the site should 
be thoroughly underdrained with tile pipe. Open ditches 
should not be made on the school grounds, as they are not 
only unsightly but are always an attraction to small boys, 
and wet feet and clothes are bound to follow. Even with 
the yard well drained, gravel, board, stone, or cement walks 
should be built from the road to the doors of the building 
and from the building to the outhouses, so that the children 
may keep their feet dry under all conditions. Moreover, 
the space under the building should be thoroughly drained, as 
well as the yard itself. 

Lighting. — ^Little need be said in this chapter regarding 
the building itself, since what has been said in the chapter in 
this book on school buildings applies to rural schools as well 
as to city schools. There are, however, special features con- 
cerning the lighting, heating, and ventilation of the rural 
school, particularly the one-room school, that require mention 
here. 

The great majority of rural one-teacher schools are 
lighted from windows on both the right and left sides of the 
room; many have windows on three sides; and one-room 
school buildings with windows on four sides are not uncom- 
mon. The best arrangement is generally conceded to be with 
windows placed on the left and rear. Where the windows are 
placed on opposite sides, a cross-light results which is assumed 
to be tiresome to the eyes. In buildings with this arrange- 
ment, shades should be provided, so that the light from the 
lower half of right-hand windows may be cut out. Under no 
circumstances should desks be placed facing windows. Light 
coming to the children from, directly in front of them is injuri- 
ous to the eyes, and while it may not always cause permanent 



26o EDUCATIONAL HYGIENE 

injury it does cause eye-strain and headache, and renders the 
children unfit for the best work possible. Whenever con- 
venient, the building should be placed with the windows facing 
the east or west so that sunlight may enter. The windows 
should be placed high, extending nearly to the ceiling, and the 
total window space should be equal to or exceed one-fifth of 
the floor space. If the walls are tinted a light gray, a soft, 
diffused light is distributed evenly about the room, restful to 
the eyes and helpful in permitting the pupils to work with the 
greatest ease. Glossily finished walls or blackboards must be 
avoided, since they cause a direct reflection instead of a dif- 
fusion of light. Windows on the right and rear should be high 
and of single sash, easily opened for ventilation and air move- 
ment. 

Heating and Ventilation. — ^The usual method of heating 
the small country school is by the means of a single stove 
placed in the centre of the room with a stovepipe ascending 
directly upward into a brick chimney the base of which is sup- 
ported on the cross-beams in the ceiling. This is uneconom- 
ical, since much of the heat is lost through the chimney. It is 
unsatisfactory in many ways, but particularly because of the 
imeven temperature resulting in the room, especially on cold 
and windy days. A slight improvement is made when the 
chimney is placed at one end of the building, the stove near 
the other end, and the stovepipe suspended from the ceiHng the 
length of the room. A much greater improvement is easily and 
cheaply made by surrounding the stove with a sheet-iron 
jacket standing a few inches from the floor and projecting a 
foot or so above the stove. All direct radiation is then cut 
off; the air inside the jacket is heated, rises, spreads about 
near the ceiling, and gradually settles downward. Cold air 
from near the floor is drawn in under the jacket. As a result 
a circulation is created which results in comparatively even 
temperature throughout the room. If the jacket fits about 
the stove properly, the stove may be placed in one cor- 
ner of the room with entirely satisfactory results, provided 



RURAL SCHOOL SANITATIOIST 



261 



the building is ordinarily weather-tight. Stoves built with 
jackets may be purchased at very reasonable prices and are 
usually more satisfactory than the ordinary stoves with make- 
shift jackets. 

Such an arrangement as just described does not especially 
improve the ventilation. However, jacketed stoves with 




BASEMENT PLAN, MODEL RURAL SCHOOL, KIRKSVILLE, MO. 
Courtesy United States Bureau of Education 

ventilating attachments are manufactured by several firms 
and are quite satisfactory. In these the jacket fits closely to 
the floor, with an opening either through the wall or through 
the floor so that fresh air from outside the building may be 
drawn in to replace the heated air rising from inside the 
jacket. Thus a constant supply of fresh air is being brought 
into the room. Provision must be made, however, for the 
removal of the foul air coming from the lungs and bodies of 
the children. This foul air, as is generally understood, 



262 



EDUCATIONAL HYGIENE 



settles to the floor of the room. It is most easily removed, 
if the chimney is of brick and extends to the floor of the 
building, by removing a few bricks in the bottom of the chim- 
ney near the floor. An upward draft is created in the 
chimney by the heat from the stovepipe. This draws the 
foul air from the floor. A circulation is created, the heat of 




FIRST FLOOR PLAN, MODEL RURAL SCHOOL. KIRKSVILLE, MO. 
Courtesy United States Bureau of Education 

the stove drawing in fresh air from outside the building, 
causing it to ascend and spread throughout the room. It is 
then taken into the lungs of the children, exhaled, and finally 
settles to the floor, from whence it is drawn off through the 
chimney by the waste heat in the stovepipe. If the brick 
chimney does not extend to the floor, an escape for the foul 
air is made by use of a large stovepipe extending from within 
a few inches above the floor upward to the chimney, surround- 
ing the regular stovepipe before it enters the chimney. Tests 
made with these jacketed stoves and ventilating attachments 



RUIIAL SCHOOL SANITATION 



263 



prove them to be both satisfactory and economical. The 
stove may be placed in one of the corners of the room as much 
out of the way as possible and it will heat the room to a sufh- 
ciently even temperature and supply every part of it with 
fresh air. Mere shields of iron to protect the nearest pupils 



WEST SIDE 



I 



TABLE 



48* :iX20- 
SKY !^' LIGHT 



SANITARV 
ORIMKIN&*— ' 
FOUNTAIN 




CASOLINE 



"^WASH BOWL. 



MTR-fiENCH 



UTRBENCM 



O : 

« i 

Z L 



_4a X20- 
SKY LIGHT 



,1 r- 



4.8-! X20 
SltYjjLICHT^ J 



1 



1 



ATTIC PLAN 



EAST SUE 



ATTIC PLAN, MODEL RURAL SCHOOL, KIRKSVILLE, MO. 
Courtesy United States Bureau of Education 

from the heat are not "jackets" and do not provide for thor- 
ough movement of the air. 

The writer has seen several one-teacher schools heated 
with ordinary hot-air furnaces placed in cellars. This neces- 
sitates the digging of cellars and is, of course, somewhat more 
expensive, although often the cellars may be used for wood- 
work shops, for agriculture, or other purposes. The plan has 
the advantage that all heating apparatus is removed from the 
schoolroom and so much space saved. The room is no more 
satisfactorily heated, however, than with the jacketed stove, 



264 EDUCATIONAL HYGIENE 

and no better ventilation is secured. Probably the extra 
expense, except where two or more rooms are to be heated, 
will not ordinarily justify the installation of the hot-air fur- 
nace except where new buildings are erected. 

Ventilation without the jacketed stove or hot-air furnace 
is difficult to accomplish. With the ordinary stove it is prob- 
ably best obtained by arranging the windows so that they may 
be lowered from the top, or by using a window-board. This 
is a board, eight to twelve inches wide, fitted into the lower 
part of the window-frame on the inside of the sash. It slopes 
inward so that the top is four or five inches from the sash. 
When the window is raised at the bottom, fresh air enters 
between the window and the board and is projected upward 
into the room in such a way that no draft is created on the 
children. Instead of a board, window-glass in a special sash 
is frequently used. This has the advantage of cutting out 
no light. Rooms should be flushed with fresh air at recesses 
and frequently at other times. Direct drafts on the children 
as seated should be avoided. 

Cleaning the Schoolroom. — The method of cleaning the 
ordinary country school building is given little attention. 
In probably more than half of the one-teacher country 
schools the janitor work is done by the teacher or by one of 
the older boys. The buildings are swept usually once or twice 
a week and with the corn broom — sometimes the floor being 
sprinkled with water before the sweeping. After the dust 
has settled it is customary to dust off the furniture with a 
feather duster, driving the dust into the air to settle again on 
the desks and chairs. It is almost needless to say this is un- 
satisfactory and insanitary. 

It will be many years before the great majority of country 
schools are supplied with many of the modern sanitary ap- 
pliances for cleaning now being used in city schools. The 
sweeping will be done for some time to come with the ordi- 
nary broom. Methods of sweeping, however, may be im- 
proved. Sprinkling the floor is effectual in preventing the 



RURAL SCHOOL SANITATION 265 

raising of dust but it binds the dirt to the floor and only part of 
it is removed. A simple improvement consists in the use of 
moist sawdust sprinkled on the floor and swept along with the 
dirt. This holds the dust and leaves the floor clean. Many 
patented materials are on the market for use on the floor to pre- 
vent a dust when sweeping. Most of them may be used several 
times. They are cheap, economical, and satisfactory in every 
way. The oil brush is also cheap and satisfactory. This is 
a sweeping-brush carrying a reservoir from which kerosene 
oil is released slowly enough to keep the bristles of the brush 
moistened. Sweeping with it is clean and dustless. Even 
with the use of patented dust-holders or of the oil brush, the 
floor must occasionally be washed with hot suds. Much of 
the dirt may be kept out of the building by providing some 
kind of iron scraper at the stoop, and encouraging the boys 
and girls to scrape carefully the extra muA and dirt from 
their shoes before entering. The scraper and a corn-husk or 
bristle mat at the door would help keep the floor clean, and 
their use might establish habits in some of the boys and girls 
which would be practised at their homes, and for which many 
overworked, tired, and weary mothers would thank the 
teacher. 

The ordinary feather duster should never be used. Large 
cloths moistened in water or oil should be used instead, and 
with them the desks, chairs, and all furniture should be care- 
fully wiped each day. 

The Water Supply. — ^The dangers from impure water, 
dirty water, the common drinking-cup, and the unclean 
drinking-cup are discussed elsewhere in the book, so that 
nothing further needs to be said here. In regard to the sup- 
ply, it may be said that every country school should have a 
handy source of pure water either on the school grounds or 
near the school grounds, and under the authority of the school 
officials, so that the purity of the water may be protected. 
If the source of the water supply is a well, it should be so 
located that pollution from outhouses or barnyards may not 



266 EDUCATIONAL HYGIENE 

take place. It must be remembered that pollution may 
result from surface water; therefore the well should be so 
constructed that surface water cannot enter. To prevent 
all foreign matter from getting in, a tight cover should be 
placed over the well. Pollution may also take place from soil 
— water percolating through the soil from a source of con- 
tamination several hundred feet away. This will take place 
when the rock strata slope from the source of contamination 
toward the well, and it must be borne in mind that the sur- 
face of the land and the underljdng rock strata are often not 
parallel and many times are foimd sloping in opposite direc- 
tions. 

Water collected from the roof of the buildings and stored 
in cisterns is used at many schools. Where this water is 
used, some arrangements should be provided so that the first 
water coming from the roof at the beginning of each storm 
will not enter the cistern. After an interval of several days 
without rain, the roof is always covered with more or less 
dust; it is also usually soiled from the droppings of birds. 

Whatever the source may be, a supply of pure, cool drink- 
ing water should be kept where it can be easily reached by 
the children at all times. The common drinking-cup should 
not be used. If the water is kept in a pail, a cover should 
be provided, also a dipper with a long handle for transferring 
the water from the pail to the drinking-cup. Much more 
satisfactory, however, is a water-tank with a faucet near the 
bottom so that the water may be drawn out without the use 
of the dipper. Such tanks are inexpensive. The double 
tanks, with an air space between the two walls, keep the heat 
out of the water for a much longer period than the others, but 
are of course more expensive. Several tanks are on the mar- 
ket with an attachment for drinking similar to the bubbhng 
fountain. 

By use of the pneumatic pressure-tank running water may 
be had for the country school at a very much lower cost 
than is usually supposed. A metal tank, the size of the ordi- 



RURAL SCHOOL SANITATION 



267 



nary kitchen hot-water tank or larger, is buried in the ground 
below the frost line to act as a reservoir and pressure- tank 
combined. It is connected with a force-pump at the well 
and with the drinking-fountain in the schoolroom. Both 
pipes to the tank must be connected at the lowest part of the 
tank. Water is pumped into the 
tank from the well by the force- 
pump. The tank is already full 
of air, which, as more and more 
water is forced in, becomes com- 
pressed, forming a pressure on 
the surface of the water and in- 
creasing until it is no longer 
possible to force in more water. 
This pressure will force the water 
through the supply pipes up to 
the drinking-fountain. This 
form of water-tank is much more 
satisfactory than an elevated 
tank inside or on top of the 
building. There is always suffi- 
cient "boy power" around the 
country school to get the tank 
filled with pressure great enough 
to supply the building with running water. Under ordinary 
conditions ^ve minutes' pumping a day will furnish plenty of 
water for drinking purposes, and ten minutes' if a water-flush 
closet is used. 

Such tanks become occasionally "water-logged," that is, 
the air becomes dissolved in the water and carried away 
until not enough is left to furnish the required pressure. 
Therefore it is necessary to have some means of pumping in 
air, either with the water or by a hand air-pump. 

The pneumatic pressure- tank, pump, piping, and drinking- 
foimtain can be purchased for from $100 to $250. With it 
not only may the sanitary drinking-fountain be provided but 




SANITARY DRINKING-FOUNTAIN, 
RUNNING WATER IN WASH- 
BOWLS AND FLUSH-TOILETS BY 
MEANS OF AN ORDINARY FORCE- 
PUMP 

From Dresslar's " Rural Schoolhouses and 
Grounds." Courtesy Bureau of Edu- 
cation 



268 EDUCATIONAL HYGIENE 

also a convenient sink for washing hands, and sanitary indoor 
closets instead of the ordinary outhouses. 

Toilets. — The most difficult problem, and the one con- 
cerning which comparatively little has been done, is that of 
supplying sanitary closets. At thousands of country schools 
in the United States to-day, no closets of any kind are pro- 
vided and children must resort to the shelter of neighboring 
woods. In thousands of others closets are provided but 
they are so filthy that the children prefer the woods. 

The great majority of one-teacher country schools will 
probably continue to use the outhouse privy for several years 
to come, and when properly constructed and cared for it may 
be satisfactory. 

The sanitary privy should be so constructed that its 
use will not be disagreeable to the user, and so that the ex- 
creta will be protected from any agencies which might dis- 
seminate disease-germs from them, such as the rain, hogs, 
insects, etc. The closet itself should be made tight, with a 
close-fitting door, a small window for light, preferably over 
the door, and an opening near the top for ventilation. In 
States where snow and severe cold are uncommon, one opening 
covered with a wire insect-netting is sufficient. In the closet 
should be placed a permanent box in which a supply of earth 
or lime should be kept, to be used every time the closet is 
used. The inside walls should be painted, and sprinkled with 
sand while the paint is yet fresh, so that a rough surface will 
be formed on which pupils and others cannot write with 
pencils. The receptacle should be made tight, with hinged 
covers, so that as little odor as possible may enter the closet. 

Probably the best form of the receptacle for all States 
where severe freezing does not take place consists of a tight 
box the floor of which is a continuation of the floor of the 
closet, and with a hinged door on the rear of the closet open- 
ing outward and upward. In this box is placed, under each 
cover, a galvanized iron or heavy tin bucket or tub to hold 
the excreta. These buckets should be taken out once or twice 



RURAL SCHOOL SANITATION 



269 



a week and the contents buried in a place where they can- 
not contaminate the water supply of the school or neighboring 
farms. The receptacle should have a small opening for the 
escape of odors, but this should be covered with a netting to 
prevent the entrance of flies 
or other insects. In colder 
countries where freezing 
would make this arrange- 
ment impracticable, a 
water-tight cesspool should 
be built for a receptacle, 
except where the soil is of 
such a character as to 
furnish a natural under- 
drainage, and where to do 
so admits no danger of 
pollution of water used for 
household purposes or for 
farm stock. In such a case 
an excavation or pit may 
be made under the closet, 
deep enough so that the 
excreta cannot be washed 
out. Whether the cesspool 

or excavation is used, both must be covered tightly so that 
rain, water, and animals, particularly insects, are prevented 
from entering. 

After each time the privy is used, earth, ashes, or lime 
should be thrown into the receptacle to cover the excreta. 
The earth used should be of rather a loamy nature, if possible, 
and porous. Sandy soil is of little value. A heap of earth 
should be collected in summer and dried in the sim for winter 
use. Lime is much better than earth. Where the cesspool 
or buckets are used, a few inches of water may be kept in the 
receptacle; this aids the excreta in fermenting and hque- 
fying. When this is done, a half -pint of kerosene oil should 




KENTUCKY SANITARY PRIVY. VERTICAL 
SECTION OF TANK AND HOUSE 

From Dresslar's " Rural Schoolhouses and 
Grounds " 



270 EDUCATIONAL HYGIENE 

be kept on the surface of the water to repel insects. A 
five-per-cent solution of crude carbolic acid or a solution of 
creosol may be, used. 

In warm climates the closets should be placed some dis- 
tance from the schools. Separate buildings should be pro- 
vided for boys and girls and the entrances should be screened 
to insure privacy. In some cases the closets must be placed 
in the same building. When this is necessary, a double par- 
tition should separate the boys from the girls and a board 
fence at least six feet high and extending from the building 
at least twenty feet should separate the entrances. In 
northern States closets are often placed in an addition to the 
school building which contains also the coal or wood supply. 
When the fuel-room is between the schoolroom and the closets 
this plan is satisfactory, provided proper care is used in the 
closets. The closets may be entered either from the outside 
or directly from the schoolroom. 

The boys' closet, wherever located, should be provided 
with a urinal as well as seats. This in its simplest form is 
a trough constructed across one end of the outhouse with 
sufficient slope to carry the water away rapidly either to the 
soil or into the cesspool. The trough should be made of metal, 
cement, or wood lined with copper or galvanized iron. 

In certain sections a chemical closet is being used which 
is reported as giving satisfaction. This consists of an all- 
metal box with a door on the front, and a seat with a cover 
fitting air-tight on top. If the closet is used in a room inside 
the school building, a three-inch pipe connects the top of the 
box with a chimney. The suction in the chimney creates a 
draft through the box which removes from it all gases and 
odors. A metal receptacle is placed inside of the box to hold 
the excreta. In this is placed two to six inches of water in 
which are dissolved certain chemicals that destroy all germs 
of diseases in the excreta. 

The most satisfactory of all closets is the sanitary flush 
closet. This is easily possible in many country schools, even 



RURAL SCHOOL SANITATION 271 

in one-room schools. A supply of water with the necessary 
pressure may be obtained from an overhead tank filled by a 
common force-pump, or from the pneumatic tank previously 
described. 

Sewage Disposal. — The great difficulty with the use of 
the water-flush closet is the disposal of the sewage. The most 
satisfactory, inexpensive way is by use of the septic tank 
and a subsurface system of distribution of the water. In its 
simplest form this is an underground tank to which the liquids 
from the closets are brought and in which they are retained 
for from twelve to twenty-four hours and then rapidly dis- 
charged into open jointed tiles from which they leak out into 
the soil to disappear. The discharge from the tank is regu- 
lated by a siphon. This intermittent flow from the tank 
into the soil allows the air to enter the soil while the tank is 
filling and oxidize the organic matter contained*in the sewage, 
converting it into harmless mineral forms suitable for plant- 
food. 

A better form of tank is the double tank, with the first 
chamber to retain the solid matter and scum until they dis- 
solve, and the second chamber to accumulate the liquids and 
discharge them intermittently by means of a siphon. The 
solids dissolve rapidly and but little settHngs remain in the 
first tank. The pipe connecting the first tank with the second 
tank is arranged so that the first tank is always filled to a 
certain depth with liquids and so that the liquids taken out 
are taken from midway between the surface and bottom. 
Then neither the scum nor settlings are disturbed. 

Satisfactory tanks may be constructed of cement by any 
farmer or carpenter at a cost varying from $25 to $50. Several 
patented septic tanks are on the market and may be purchased 
at a reasonable cost. 

Conclusion. — Improved rural school sanitation is impera- 
tive, not only for the sake of the children who are compelled 
by law to attend the schools for several of the most plastic 
years of their lives, but because of the direct and indirect 



272 EDUCATIONAL HYGIENE 

effects on rural hygiene in general. Progress in sanitation 
and preventive medicine has quite largely passed by the 
rural portions of our country, and the public school is the 
chief instrument for catching up with the times. Through 
Federal dissemination of information, through State aid in 
money and expert guidance, and through teachers and county 
superintendents better educated in rural hygiene, we may ex- 
pect speedy readjustments. 

The following statement of minimum sanitary essentials 
for rural schools is authoritative and very irnportant: 

MINIMUM SANITARY REQUIREMENTS FOR RURAL 

SCHOOLS 1 

It is the desire and purpose of this committee to help establish 
a standard of fundamental health essentials in the rural school and its 
material equipment, so that attainment of this minimum standard 
may be demanded by educational authorities and by public opinion 
of every rural school throughout the country. 

Possession of the minimum sanitary requirements should be 
absolutely necessary to the pride and self-respect of the community, 
and to the sanction and approval of county, State, and other super- 
vising and interested ofificial or social agencies. 

Neglect of anything essential for health in construction, equip- 
ment, and care of the rural school plant is at least an educational sin 
of omission and may reasonably be considered a social and civic crime 
or misdemeanor. 

The country school should be as sanitary and wholesome in all 
essential particulars as the best home in the community. Further, 
it should be pleasing and attractive in appearance, in furnishings, and 
in surroundings, so that the community as a whole may be proud of 
it; so that the pupils and teacher may take pleasure in attending 
school and in caring for and improving it. 

^ Proposed by the Joint Committees on Health Problems in Education of 
the National Council of the National Education Association and of the Ameri- 
can Medical Association. Pamphlet published by the American Medical As- 
sociation, Chicago. See also Dresslar's bulletin (U. S. Bureau of Education) 
on "Rural Schoolhouses and Grounds" and Rapeer's " Standardization of the 
Rural School Plant" in School and Society for Feb. 15, 191 5, and his survey 
of "Rural School Hygiene" in the Pennsylvania "Rural School Report" to 
the State Educational Association, 1914. 



RURAL SCHOOL SANITATION 273 

I. Location and Surroundings 

The school should be located in as healthful a place as exists in 
the community. 

Noise and all other objectionable factors should be eliminated 
from the immediate environment of the rural school. 

Accessibility. — Not more than two miles from the most distant 
home, if the children walk. Not more than six miles from most dis- 
tant home, if school wagons are provided. 

Drainage. — School ground must be well drained and as dry as 
possible. If natural drainage is not adequate, artificial subsoil drain- 
age should be provided. 

Soil. — As every rural school ground should have trees, shrubs, 
and a real garden or experimental farm, the soil of the school grounds 
should be fertile and tillable. Rock and clay soil should always be 
avoided. If the soil is muddy when wet, a good layer of sand and fine 
gravel should be used to make the children's playground as useful as 
possible in all kinds of weather. 

Size of School Grounds. — For the schoolhouse a^jid playground at 
least three acres are required.^ 

Playground is not a luxury but a necessity. A school without a 
playground is an educational deformity and presents a gross injustice 
to childhood. 

Arrangement of Grounds. — The school grounds should have trees, 
plants, and shrubs grouped with artistic effect but without interfering 
with the children's playground, 

11. Schoolhouse 

The schoolhouse should be made as nearly fire-proof as possible. 
Doors should always open outward and the main door should have a 
covered entrance; a separate fuel-room should be provided, also separate 
cloak-rooms for boys and for girls. 

A basement or cellar, if provided, should be well ventilated and 
absolutely dry. 

The one-teacher country school should contain, in addition to the 
classroom: 

(a) A small entrance-hall, not less than 6 by 8 feet. 

{h) A small retiring-room, not less than 8 by 10 feet, to be used 
as an emergency-room in case of illness or accident, for a teacher's 

^ If the rural school plant includes the additional features (a teacher' s home, 
a garden, and an experimental farm), which are already in some progressive 
States accepted and established as educational essentials, then the school 
grounds should contain eight to ten acres. 



274 EDUCATIONAL HYGIENE 

conference-room, for school library, and for health inspection, a fea- 
ture now being added to the work of the rural school. 

(c) A small room, not less than 8 by lo feet, for a workshop, 
for instruction in cooking, and for the preparation of refreshments 
when the school is used, as it should be, for social purposes. 

Classroom should not be less than 30 feet long, 20 feet wide, and 
12 feet high. This will provide space enough for a maximum of 
thirty pupils. 

III. Ventilation and Heating 

The schoolroom should always receive fresh air coming directly 
from out of doors in one of the following arrangements: 

{a) Through wide-open windows in mild weather. 

(b) Through window-board ventilators under all other con- 
ditions, except when, with furnace or jacketed stove, special and ade- 
quate inlets and exits for air are provided. 

Heating. — Unless furnace or some other basement system of heat- 
ing is installed, at least a properly jacketed stove is required. (No un- 
jacketed stove should be tolerated in any school.) 

The jacketed stove should have a direct fresh-air inlet about 12 
inches square, opening through the wall of the schoolhouse into the 
jacket against the middle or hottest part of the stove. 

The exit for foul air should be through an opening at least r6 
inches square on the wall near the floor, on the same side of the room 
as the stove is located. 

A fireplace with flue adjoining the stove chimney makes a good 
exit for bad air.^ 

Temperature. — Every school should have a thermometer, and the 
temperature in cold weather should be kept between 66 and 68 de- 
grees Fahrenheit. 

IV. Lighting 

The schoolroom should receive an abundance of light, sufficient 
for darkest days, with all parts of the room adequately illuminated. 

The area of glass in windows should be from one-fifth to one- 
fourth of the floor area. 

The best arrangement, according to present ideas, is to have the 
light come only from the left side of the pupils and from the long wall 
of the classroom. Windows may be allowed on rear as well as on the 

^ The following arrangement for ventilating-flue is required in one Western 
State: A circular sheet -steel smoke-flue, passing up in centre of ventilating 
shaft (foul -air exit), 20 inches square in the clear. 



RURAL SCHOOL SANITATION 275 

left side. High windows not less than seven feet from the floor may- 
be permitted on the right side as an aid to cross- ventilation, but noi 
for lighting. 

There should be no trees or shrubbery near the schoolhouse which 
will interfere with the lighting of the classroom. 

The school building should so face with reference to the windows 
that the schoolroom will receive the direct sunlight at some time dur- 
ing the day. 

Shades should be provided at tops and bottoms of windows, with 
the dark shades at top, so that light may be properly controlled on 
bright days. 

Schoolroom Colors. — The best colors for the schoolroom in relation 
to lighting are: 

Ceiling — white and light cream. 

Walls — light gray, green. 

Blackboards — black. 

V. Cleanliness 

The schoolhouse and surroundings should be kept as clean as a 
good housekeeper keeps her home. 

{a) No dry sweeping or dusting should be allowed. 

{h) Floors and furniture should be cleaned with damp sweepers 
and oily cloths.^ 

(c) Scrubbing and airing are better than any form of fumigation. 

VI. Drinking Water 

Drinking water should be available for every pupil at any time of 
day which does not interfere with the school programme. 

Every rural school should have a sanitary drinking-fountain 
located just inside or outside the schoolhouse entrance. 

Drinking water should come from a safe source. Its purity should 
be certified by an examination by the State board of health or by some 
other equally reliable authority. 

A common drinking-cup is always dangerous and should never be 
tolerated. 

Individual drinking-cups are theoretically, and in some conditions, 
all right, but practical experience has proven that in schools individual 
cups, to be used more than once, are unsatisfactory and unhygienic. 
Therefore they are not to be advocated nor approved for any school. 

^ Sweeping compounds in moisture-proof containers may be obtained in the 
market. 



276 EDUCATIONAL HYGIENE 

Sufficient pressure for running water for drinking-fountain or 
other uses in the rural school may always be provided from any source 
without excessive expense by a storage-tank or by pressure-tank with 
force-pump. 

VII. Water for Washing 

Children in all schools should have facilities for washing hands 
available at least: 

(a) Always after the use of the toilet. 

(b) Always before eating. 

(c) Frequently after playing outdoors, writing on blackboard 
or doing other forms of hand-work connected with the school. 

Individual clean towels should always be used. 
Paper towels are the cheapest and most practicable. 
The common towel is as dangerous to health as the common 
drinking-cup. 

VIII. Furniture 

School seats and desks should be hygienic in type and adjusted to 
the size and needs of growing children. Seats and desks should be 
individual — separate — adjustable — clean. 

Books and other materials of instruction should not only be sani- 
tary but attractive enough to stimulate a wholesome response from 
the pupils. 

IX. Toilets and Privies 

Toilets and privies should be sanitary in location, construction, 
and in maintenance. 

(a) If water-carriage system for sewage is available, separate 
toilets for boys and girls should be located in the schoolhouse, with 
separate entrances on different sides or corners of the school building. 

(b) If there is no water-carriage system, separate privies should be 
located at least fifty feet in the different directions from the school- 
house, with the entrances well screened. 

(c) The privy should be rainproof, well ventilated, and one of the 
following types: 

(i) Dry earth closet. 

(2) Septic-tank container. 

(3) With a water-tight vault or box. 

All containers of excreta should be water-tight, thoroughly screened 
against insects, and easily emptied and cleaned at frequent intervals. 



RURAL SCHOOL SANITATION 



277 



No cesspool should be used unless it is water-tight and easily- 
emptied and cleaned. 

All excreta should be either burned, buried, treated by subsoil 
drainage, reduced by septic-tank treatment, or properly distributed 
on tilled land as fertilizer. 

X. All Schoolhouses and Privies Should be Thoroughly and 
Effectively Screened against Flies and Mosquitoes 

XI. Schoolhouses and Outhouses Should be Absolutely Free 

FROM All Defacing and Obscene Marks 

XII. Buildings Should be Kept in Good Repair and with 

Whole Windows 



STANDARDS 



Provision and equipment of adequate school plant depends on in- 
telligence, interest, pride, and financial ability of community. 

Maintenance of a clean and sanitary school plant depends on 
efficient housekeeping, and on interest and willing co-operation of 
pupils. 

No community should be satisfied by the minimum requirements 
indicated in the foregoing, but every country school should be so at- 
tractive and well equipped as to minister with some abundance of 
satisfaction to the physical, mental, aesthetic, social, and moral well- 
being of those who provide it, who own it, who use it, and who enjoy it. 

Present Conditions 

Among the reasons which explain the present deplorable con- 
ditions of rural schoolhouses, the following are prominent: 

(a) Low architectural and sanitary standards in rural regions 
generally throughout the country. 

(b) Ignorance regarding the physical, mental, social, and moral 
effects of unattractive and unsanitary school buildings on the children 
and on the community as a whole. 

(c) False economy expressed by local school boards in failure to 
vote enough money to build and maintain suitable school buildings. 

(d) Lack of supervision or assistance by the State, which is usually 
necessary to maintain desirable standards. 



278 EDUCATIONAL HYGIENE 



Improvement 

How shall the rural schools throughout this country be improved 
up to a reasonably satisfactory standard? 

I. By a popular campaign of education regarding the conditions 
desirable and possible in the country school. Such a campaign would 
profitably include many or most of the following: 

(a) The United States Bureau of Education and State depart- 
ments of education should furnish plans and instructions for construc- 
tion and equipment of rural school buildings. 

The United States Bureau of Education in Washington is already 
supplying, on request, valuable help of this kind, and a few State 
departments of education are demonstrating what may be done by 
supervision and support which aids without controlling. 

(&) State departments of education should supply supervision of 
rural schools and should have power: 

(i) To condemn insanitary and wholly unsuitable buildings. 

(2) To give State aid to rural schools when the local authorities 
fulfil certain desirable and reasonable conditions. 

(c) Ideas and standards of school sanitation should be inculcated 
in minds of local school patrons and school authorities who control 
school funds and who administer the affairs of the schools. Public 
lectures on health topics should be provided in the schoolhouse and 
elsewhere. 

{d) Effective school health courses should be introduced in normal 
schools and teachers' institutes. 

Better education of rural school-teachers, county superintendents, 
and rural school supervisors in the principles and practise of school 
hygiene and sanitation should be assured. 

{e) Interest in and enthusiasm for the improvement and care of 
all features of the school and its surroundings which affect health and 
happiness should be inspired in the minds of rural school pupils. 

Organizations such as "Pupils' Board of Health," " Civic Leagues," 
or "Health Militias" may profitably be formed among pupils. 

(/■) Organizations like "The Granges," Women's Clubs, County 
Medical Societies, and other groups so situated that they may further 
the cause of health and efl&ciency, should co-operate with the rural 

school. 

(g) Attractive but rehable health information should be furnished 
abundantly by the public press. 

II. Emulation and competition should be recognized and re- 
warded in ways that will promote wholesomely and progressively the 
welfare of the community as a whole. 



RURAL SCHOOL SANITATION 279 



TEN SANITARY COMMANDMENTS FOR RURAL SCHOOLS 

In every school which may be considered passably sanitary the 
following conditions shall obtain: 

1. Heating by at least a properly jacketed stove. (No unjacketed 
stove to be allowed.) 

Ventilation by direct outdoor-air inlets and by adequate and di- 
rect foul-air outlets. 

2. Lighting from left side of room (or from left and rear) through 
window space at least one-fifth of floor space in area. 

3. Cleanliness of school as good as in the home of a careful house- 
keeper. 

4. Furniture sanitary in kind, and easily and frequently cleaned. 
Seats and desks adjustable and hygienic in type. 

5. Drinking water from a pure source provided by a sanitary 
drinking-fountain. 

6. Facilities for washing hands, and individual Rowels. 

7. Toilets and privies sanitary in type and in care (with no cess- 
pools unless water-tight) and no neglected privy boxes or vaults. 

8. Flies and mosquitoes excluded by thorough screening of school- 
house and toilets. 

9. Obscene and defacing marks absolutely absent from school- 
house and privies. 

10. Playground of adequate size for every rural school. 



CHAPTER XVI 

HYGIENIC SCHOOL ENVIRONMENT 

The Problem. — ^The public-school system must be satisfied 
with nothing less than the ideal, not only in methods of teach- 
ing and the results these methods accomplish but also in the 
surroundings the school gives the pupils while they are in its 
care. The public school should be a leader not only in the 
matters of mere learning but also in giving lessons, by ex- 
ample, on how to live with the end in view of securing the 
proper sanitary surroundings in the homes and business world. 
The public of every school community has a right to demand, 
that only the best principles and the highest ideals should 
emanate from the school, with respect to cultivating the mind, 
methods of living, and habits of life. Childhood is the im- 
pressionable time. What is woven into the mind and heart 
and nervous system in youth is likely to persist to the end. 
If a child grows up in unclean surroundings, his life will proba- 
bly show throughout something of the influences of his youth. 
Insufficient clothing, bad food, poor light, foul air — all these 
cast their blight over children. Some one has said that the 
race advances on the feet of little children. If the children of 
our present day can have better conditions under which to de- 
velop than did the children of the generation just past, then 
the race has made a distinct advance. If better habits can 
be developed in children that now attend our schools, then 
the race has so far gained over what it received from the 
schools of the past. 

280 



HYGIENIC SCHOOL ENVIRONMENT 281 

The responsibility of those who administer our schools is 
a tremendous one; the call to higher and better things is an 
insistent one. What any new day may bring forth can be, 
of course, only problematical, but all things point to that 
better time when every child in our schools will not only be 
well taught but will have about him every life-giving and 
healthful condition: when he will have God-given fresh air 
to breathe and not the baked air that devitalizes; when he 
will have pure water to drink and not the germ-laden fluid 
from well and stream and pool that often carries disease and 
death; when the great and beautiful light of God's out-of- 
doors will have unhindered access to every schoolroom in 
place of the half-lights and shades that dim the eye and worry 
the nervous sys.tem; when every child shall have playground 
space enough to exercise all his body powers; when every 
teacher and school administrator shall know accurately what 
school conditions ought to be, and shall leave no stone un- 
turned until those conditions are obtained; when the world 
shall demand that every school be a perfect place for children 
and that there they may attain to the fullest development of 
their mental and physical powers. This problem of better 
sanitary conditions in our schools is one that must be soon 
solved. We are at the dawn of a better day as to the care of 
our children, and there can be no work that is more important. 

Some Sanitary Conditions. — This problem of getting the 
best sanitary conditions in and about the schoolroom is not 
merely a school problem; it is quite clearly a community 
problem as well. The school will not for any considerable 
length of time be very much better or very much worse than 
the people want it to be, either as to the physical condition of 
the building or the quality of the teaching that is done in the 
building. These statements are especially applicable to the 
United States, where every enterprise rests directly or in- 
directly on public opinion, public sentiment, and the will of 
the people. Any nation-wide survey of American schools 
will lead to the conclusion that there are thousands and thou- 



282 EDUCATIONAL HYGIENE 

sands of school communities that need to wake up and then 
to catch up with the best thought of the time on how to take 
care of the children that must attend the schools. The re- 
sponsibility for bad conditions is seen to be especially heavy 
when it is reahzed that in most of the States there are com- 
pulsory-education laws and that children must be submit- 
ted to the conditions of the schoolroom, be those conditions 
good or bad. In a multitude of communities children are 
forced into schools where poor light, air that is continually 
foul, and contaminated water endanger the health and sow 
the seeds of disease and death. It is a hard thing to be com- 
pelled to say, but there are many communities where the school 
surroundings are so bad that the children would be far better 
off out of school than in. Practically every school survey 
reveals this fact. There is a tremendous need of the gospel 
of school hygiene. Every person that preaches it is indeed a 
missionary. This gospel needs to go into many dark places, 
for there are hundreds of schools in which those in authority 
violate every known law of the proper housing and physical 
care of children. 

There are schools that are on low, small, and poorly drained 
sites. Especially is this true in many country districts where 
the schools were placed on land that was not good for any- 
thing else in particular. There are numerous schools whose 
architecture is that of a barn, whose ventilation is unscien- 
tific, inefficient, and continually harmful, and whose lighting 
systems had no further planning than the leaving of a few 
square holes in the walls and filling them with windows. 
It is hard to refrain from making seemingly hysterical and 
overcolored statements when one discusses actual conditions 
in a multitude of American schoolrooms. There are rooms 
into which the light is admitted from all four directions, 
others into which the fight comes from three directions, and 
an uncounted number that receive light from two opposite 
sides. 

The unjacketed stove of our fathers is still doing duty in 



HYGIENIC SCHOOL ENVIRONMENT 283 

schoolrooms everywhere, and many an urchin is being baked 
on one side and chilled on the other while he seeks to follow 
the devious ways of knowledge. Even in many instances 
where more elaborate systems of heating have been installed, 
the most deplorable results are obtained. Foul air-ducts do 
not do their work properly, rooms are overheated, and the 
air is baked till it becomes dryer than the atmosphere in the 





ONE ROOM TOWNSHIP CENTRALIZED & CONSOLIDATED 

■ RATIO LESS THAN 1:8 [BAD] g BETWEEN RATIOS 1:8 AND 1:5 [POOR] 

□ RATIO 1:5 AND OVER [PERMISSIBLE] 

RATIO OF WINDOW SPACE TO FLOOR SPACE IN OfflO RURAL SCHOOLS 

From Ohio School Survey 

most arid regions of the earth. Colds, coughs, and kindred 
troubles come, children are carried off by death, and the 
ignorant school community sighs and wonders at the ways of 
a mysterious Providence that sees fit to strike down the 
fairest flowers in this garden of earth. If such communities 
would abandon attributing to Providence the results of their 
own ignorance and laziness, and arouse themselves from their 
lethargy and indifference, their children would have a better 
chance to live out the lives that Providence has offered them. 
Pure Drinking Water. — Along with the matters of ven- 
tilating, lighting, and heating comes the question of obtain- 
ing a proper supply of drinking water. The best way to pro- 
vide water is by means of drinking-f ountains, but sometimes 



284 EDUCATIONAL HYGIENE 

the water so provided is of poor quality because of the loca- 
tion of the school or the community in which the school is 
located. The best that can be done is the thing to do, of 
course, but there is little or no excuse for the criminal negli- 
gence and ignorance that prevail in some schools. In all 
too many cases, in rural communities, water is carried from 
neighboring farms and is allowed to stand all day exposed 
to the foul air and the dust of the schoolroom. No more is 
brought till the supply in the bucket is exhausted, or till it 
gets so bad or so warm that it is necessary to go for more. 
In some cases the water-supply is obtained from springs or 
shallow wells that catch the drainage and possible contamina-^ 
tion from the surrounding ground. Where such conditions 
prevail the cause is usually found in the fact that those re- 
sponsible are either too ignorant or too niggardly to provide 
the proper kind of a well on the school premises. There is 
nothing in the world so sacred as the taxpayer's dollar, not 
even the lives of little children, in the view of many men who 
administer the financial ends of school organizations. Every 
human being must have plenty of pure, fresh water every 
day if he is to keep in health. The State has undertaken to 
gather children together in groups and to educate them. The 
State commits a crime when it does not safeguard the health 
and lives of these little ones on whom the future depends. 
The foolish, the careless, the ignorant, and the indifferent 
ought never to be intrusted with the care of the children in. 
our schools. 

Many additional details might be given to show that many 
conditions in our schools the country over are far from satis- 
factory from a hygienic standpoint. It is safe to say that 
very few school-buildings even approximate ideal conditions. 
The surface has barely been touched in what has been written 
above. There are many schoolrooms that are looked after 
by teachers and janitors who have never even heard of some 
of the modern appliances for the proper care of school build- 
ings. For the sake of reminding the reader in regard to the 



HYGIENIC SCHOOL ENVIRONMENT 285 

conditions, methods, and appliances that ought to be in use in 
every ideally equipped and managed school, a list of subheads 
given by the editor of this volume under the general topic of 
'' School Sanitation" is submitted herewith: sites, archi- 
tecture, ventilation, lighting, heating, drinking-water, drink- 
ing-fountains, cleaning and vacuum cleaners, school baths, 
hygienic toilet facilities, seats and desks, decoration, fire-proof 
construction, rest and emergency rooms, play-rooms and roof 
playgrounds, open-window rooms, supervision of janitors, 
hygienic cloak-rooms, drying and warming seats, investiga- 
tions of recirculation, humidity, air-cleaning, disinfection, etc. 
This is rather a formidable list, is it not? One can readily 
surmise that to understand and to apply the things suggested 
takes something more than the mere qualification of being 
elected to a school ofhce or of being able t« pass a teacher's 
examination in the three R's with accessories. The proper 
hygienic administration of a modern school is a big problem. 
The general schoolroom conditions that prevail in this country 
are far from satisfactory — every survey shows that. The State 
cannot fairly and honestly force children to attend school and 
then not properly care for their health. There is splendid 
public-health work ahead for the schoolmaster and the school- 
mistress of the present time. 

Sanitary Surveys. — The enthusiastic inquirer into what 
ought to be done under the circumstances can be given plenty 
of things to do. The first thing that ought to be on the pro- 
gramme of school betterment from a sanitary standpoint, in 
every State, is the matter of a proper sanitary survey. If 
every schoolhouse in the nation could be visited by one or 
more experts and its physical surroundings made note of, 
if all the data in regard to every schoolhouse could be set 
down on standard forms in use by all other experts so that 
there could be no confusion in regard to the results of indi- 
vidual surveys, then a big start would be made toward getting 
better conditions. If, for instance, it could be known for any 
given school year just how many schoolhouses in this coun- 



286 EDUCATIONAL HYGIENE 

try are improperly heated, lighted, and ventilated, how many 
have poor water-supplies, how many owe their poor condition 
to backward and ignorant school communities, etc., every 
thinking person would derive a tremendous inspiration and 
help in this fight for better things. There is no stimulant like 
scientifically determined standards and exact knowledge. 
A thorough national survey of our schools would let all the 
world know just what are the conditions in every individual 
school. With the knowledge of poor conditions in any given 
school district would come ridicule, then shame, then deter- 
mination to have better things. Community pride would be 
appealed to, and straightway the children in that community 
would have a better chance to enjoy life and health and, 
withal, to get a better education because of better, healthier 
bodies with which to get that education. It will probably 
be many years before there will be a general, simultaneous, 
national school survey, but it ought nevertheless to be made. 
There is no reason why the more progressive States, like Ohio, 
cannot take up this work.^ The results would be invaluable 
not only in a direct way to the schools themselves but to the 
State at large in the way of educating the people. There 
is an almost immeasurable opportunity here for some State 
to take the lead in this direction. 

Occasionally a school survey is undertaken by sending out 
blanks for teachers or others to fill out. This method is 
good so far as it goes, but it has many faults. With the pres- 
ent attitude of the public toward such movements, how- 
ever, it is about the only method that is attainable at this 
time. Those who administer pubHc funds have not yet 
come to the place where they will permit a body of experts 
sufficient remuneration for travelling about over the country 
and finding out things that only experts can find out. Even 
if every questionnaire blank sent out in any given survey were 
answered in full, much of the information obtained thereby 
would be inaccurate and unreliable. How many teachers 
* See recent survey reports for Ohio, Pennsylvania, and Illinois. 



HYGIENIC SCHOOL ENVIRONMENT 287 

or school officers, even with stated standards, are proper 
judges of ventilation, lighting, heating, the quality of drink- 
ing water, the proper colors to put on the walls and ceilings 
of schoolrooms, hygienic cloak-rooms, humidity, disinfection, 
and kindred topics that have to do with the proper care 
of children? Even where, for instance, the ratio of window 
space to floor space is the correct one and the teacher knows 
that ratio or standard to be correct, there may actually be 
an insufficient amount of light coming into the schoolroom. 
Neighboring trees or buildings or other obstructions may shut 
out light. These interfering and complicating features may 
easily be lost sight of by the inexpert. A report may show that 
a building is thoroughly equipped with a plenum system of 
heating and ventilating and yet some part of that system may 
be working in a manner that is far from satis^ctory. Drink- 
ing water may be obtained from a source that ordinarily 
would be safe enough, and kept in sanitary drinking- fountain 
tanks, and yet that water may be daily endangering the lives 
of those who drink it. The questionnaire method, while it is 
the best that can be used under most circumstances, has, 
then, its apparent dangers of misinformation and unreliabil- 
ity. The best method is to send the expert in person to in- 
spect and report. A mass of information gathered in this 
way will then form a reliable basis on which to base con- 
clusions. 

The average school executive, however, will ask what he 
can or ought to do under the existing circumstances, and not 
what he might do with plenty of money and an abundance 
of expert assistance. The first thing for any school execu- 
tive to do, no matter whether he be superintendent, princi- 
pal, teacher, or other person in authority, is to begin with 
what he has in hand in the way of equipment. He can 
first inform himself as to needed standards and requirements, 
and then by investigation and experiment find out whether 
the pupils under his care are working and living under satis- 
factory conditions. He can measure the window space in 



288 EDUCATIONAL HYGIENE 

each room and find out whether, according to the best stand- 
ards, sufficient light is being admitted. He can measure the 
cubic contents of each room and ascertain whether each pupil 
has enough air space. He can measure the air currents that 
enter and leave each room in a plenum system and find out 
whether each pupil is receiving enough air per minute. He can 
test the drinking water or send it to a State chemist or other 
chemists for investigation. He can cultivate his judgment 
by the use of his common sense and scientific standards as 
to whether the colors on the schoolroom walls are what they 
ought to be. By experiment and standard instruments he 
can determine whether the humidity of his schoolrooms is 
what it should be. He can inspect closely the work of janitors 
and see whether they get reasonably satisfactory results. 
He can, after a little reading and other investigation, deter- 
mine whether a thorough, workable, and constantly used 
system of disinfection should be installed. In short, after 
some study of his sanitary situation, he can give a tolerably 
accurate account of it and what it needs. This kind of a 
sanitary survey is likely to bring the best results because of 
its having been done by the person who, more than any one 
else, is responsible for it and for its being remedied. Ex- 
pert sanitary surveys made at large have the advantage of 
being well done, but the survey made by the person that must 
remedy conditions found to be bad is ordinarily of the most 
use, because it is more likely to result in efficient and forcible 
action. The school official who is anxious to make a sanitary 
survey and to get health results therefrom need not lack for 
information as to what to do. The health officers of his com- 
munity and the constantly growing body of literature on the 
subject of public-school health will thoroughly inform him, if 
he is anxious to be informed. One of the greatest services 
that any school official can perform for his community is to 
make or have made a complete sanitary survey of the school 
property under his care.^ 

^ For cities, the sanitary inspection forms used by the Philadelphia schools 
will prove suggestive. 



HYGIENIC SCHOOL ENVIRONMENT 289 

The Health Officer and the School.— The local health 
officer, following the rounds of his ordinary duties in looking 
after the public health, can do no greater service than that of 
constantly agitating the matter of better sanitary conditions 
in the schools. Agitation ought to be the first thing on his pro- 
gramme, and then he ought to see to it that all the teachers 
and school officers who come under his jurisdiction are thor- 
oughly informed as to reasonable sanitary standards and know 
just what to do under all ordinary circumstances. School of- 
ficials may want to have sanitary matters just right and yet 
may not know just how to obtain their ends. Energetic and 
well-informed health officers can step in at this juncture and be 
of inestimable service to the schools. Such officers can furnish 
definite and clear rules for the construction and sanitary main- 
tenance of schoolhouses. They can inteij)ret and apply 
school-health legislation. Through the legal powers given 
them they can usually close up schoolrooms that are en- 
dangering the health of children and that will never be im- 
proved except through some such vigorous compulsion. 
Especially can State boards of health, when given enough 
support by law, serve their States in a great and vigorous 
way. This is markedly true in cases where the executive 
officers of such boards are men of unusual vigor, enthusiasm, 
and devotion to the cause in which they are enlisted. 

The particular thing that any health officer or board can do, 
with the assurance of rendering an immediate service, is the dis- 
semination of information as to sanitary matters, in language 
that is clear, definite, and untechnical. Further than this, if 
such information, when scientific, can be enacted into law or if 
the decisions of health boards can have the weight of law, the 
communities affected will have a still greater service rendered 
them. Perhaps one of the most striking instances of a State 
board of health that is serving the schools of its State in 
this definite way is furnished by the health board of a middle- 
Western State (Indiana). Legal enactments and judicial 
decisions have given to the actions of this board the weight 



290 EDUCATIONAL HYGIENE 

of law. This board has a great advantage in this direction. 
It demands right conditions. School people throughout the 
State must obey its behests. The problem before the board, 
then, is extremely simple — ^put into clear and direct language a 
set of rules, based on the best modern standards, to govern the 
construction and care of all school-buildings. Since these rules 
have the weight of law, they must be obeyed. Such a set of 
rules has in this State recently been formulated. These 
rules cover everything from the minimum number of square 
feet per pupil on the playground to the reheating of air under 
certain conditions. Any intelligent person can understand 
these rules. They operate for all. The first and the per- 
manent effect has been the Hfting of sanitary operations in 
all schools to a much higher level. Fortunate is the school 
system of any State that can have such imiform and thorough 
administration as to health matters. Where they are under 
the supervision of the State boards, and where these State 
boards have definite and clear-headed policies as to what 
ought to be done, the local boards of health can, of course, 
attack their problems with more vigor. And where there are 
in the State department of education efficient departments 
of hygiene, the same results or better can be obtained. 

Sites. — ^AU school sites should be easy of approach, some- 
what elevated, and thoroughly drained. Water should never 
stand on a school yard. A schoolhouse should not be near 
any condition or situation that might impair the work or 
the health of the children. No school should be near any 
industry that pollutes the atmosphere, or near any stagnant 
water or other objectionable situation. Every school should 
have a playground of not less than one acre. Especially is 
this true in the country, where land is comparatively cheap. 
In addition to the playground, there should be room for 
school gardening, and for other activities that have to do with 
health and the implanting of correct ideals as to what beauti- 
ful school grounds ought to be. Where there is a consoli- 
dated school, ten to twenty acres for a school farm should be 



HYGIENIC SCHOOL ENVIRONMENT 



291 



added. The playground part of the school site should con- 
tain an area of not less than thirty square feet for each pupil. 
The grounds should really be much larger than this standard. 
In the opinion of the writer, healthful out-of-doors play is far 











Viamond 



!> a^~fir-n a O fi n^'"iK^xy'£ w « n rji \.-i r<^ a 




f-or^^^ 7r^€^ 



t> <B e 

« « « Q^ 

« O O & o 

POOP 



Bjtp&r'ime,n/al 

y<xae.-l-oJbM 

^ard*n 




\i \> a V ij tv 



Ti-acfjery 
Oarttcn 



G 
£ 



Ht> o ■ tf o o o e 
c 

tin Effiartnwfthi/ ie 



lt> f> ft c^ <a a rf 



M. 1 



Esp^r/menfa/ Farm 
SAerer 



Cbv/inzY ScffooL fAZ/\ 

ica/e 



(From Dresslar's " Rural Schoolhouses and Grounds.' 



Courtesy U. S. Bureau of Education.) 

to be preferred to any and all systems of calisthenics in school 
or other rooms. The child that has the room to run and 
play as he desires has a big help in the matter of having good 
health. If his playground is well drained and gravelled, 
free from depressions in which water can stand, and equipped 



292 EDUCATIONAL HYGIENE 

with enough apparatus to afford proper exercise for him, he 
is fortunate indeed; for his school will probably be more 
attractive to him and his tendency to be out of, or late in ar- 
riving at, school will be reduced to a minimurn. One of the 
greatest assets in maintaining the health of any set of school- 
children is to have a school site that is big, healthful, and 
serviceable enough to make it possible for children to get the 
most out of life. "Excessive housing" has been called one of 
the dangers of modern civilization. It is the duty of the school 
to combat this tendency by having school grounds big enough 
to serve to the fullest the needs of all the children. ^ 

Standards of Construction. — ^The construction of school 
buildings is an extensive topic. It includes all the details of 
planning and arrangement, the specification of materials, 
and construction according to the latest and most approved 
ideas as to sanitation. However, some general rules can be 
laid down that should apply to the construction of almost 
every schoolhouse. Local conditions may possibly produce 
variations from these standard rules, but in the main they 
probably should prevail. The first of these suggestions is 
that no school building should be more than two stories in 
height, above the basement. The objection will at once be 
made that in cities, where the price of real estate is largely 
beyond the reach of school funds and where the nmnber of 
children to be taken care of is large, it is absolutely necessary 
to build schoolhouses more than tw^o stories in height. The 
necessity may in certain atypical cases seem to exist, but there 
are some people who claim that the health and lives of chil- 
dren are more precious than real estate, and that every school 
should have room enough in which to take care of every 
child in the way it ought to be taken care of. Children more 
than two stories from the ground, with the best of modern 
fireproofing of buildings, are running serious dangers from fire, 
and they probably undergo undue strain in constantly climb- 
ing two or more flights of stairs. The second general rule in 

1 See Chapter XXIV. 



HYGIENIC SCHOOL ENVIRONMENT 



293 



construction is that all school-buildings shall be constructed 
so as to be absolutely fire-proof or as nearly so as is possible. 
All exits should be as wide as possible, and all interior wood 
finish should be as small in amount as possible. Further- 
more, all wood finish and all plastering should be so constructed 
as to minimize or prevent the collection of dust. Every 
window-sash ought to contain as few panes of glass as possible, 
and where it seems difficult to light rooms properly prism 
glass should be used. Especial attention should be paid to 
the matter of lighting, for mistakes in this direction are often 
not easily detected and may produce much harm. 

Heating and ventilating systems should take fresh air from 
outside the building, diffuse it throughout each schoolroom, 
and carry out the foul air at a rate of not less than eighteen 
hundred cubic feet per hour for each two hundred and twenty- 
five cubic feet of schoolroom space, in all conditions of the 
outside atmosphere. Even where stoves are used, apparatus 
should be installed to take air from outside the school- 
house and to conduct to the outside the foul air. The health 
authorities in any community should prevent the use of a 
school-building that does not approximate in fresh-air ef- 
ficiency the standard set out above. Automatic tempera- 
ture regulation should be provided in all buildings with cen- 
tral heating systems. No matter how faithful the teacher or 
the janitor may be in looking after the heating and ventila- 
tion, he cannot be as efficient as the best modern regulating 
apparatus. The very fact that a teacher is in and inured to 
the schoolroom often disquahfies him for quickly and ac- 
curately judging whether the room is too warm or too cold, 
and whether fresh air is needed. The usual temperature 
formerly recommended for the schoolroom was seventy de- 
grees, and the ordinary regulation apparatus is set for that 
figure, but children may have as good or better health at a 
lower temperature, especially if there is a proper degree of 
humidity in the schoolroom. The usual heating apparatus 
should provide easily a temperature ranging from sixty-six to 



294 EDUCATIONAL HYGIENE 

sixty-eight degrees. In summary, the proper amounts of heat, 
light, and fresh air are the first things to be taken into con- 
sideration in the erection of any building. 

Another feature that must be looked after carefully is 
the proper installation of toilet and wash-room facilities. 
Cleaning the building should also be made as easy as possible. 
Vacuum sweepers and every other modern appHance ought 
to be put in the trained hands of the janitors. Wherever 
possible, inclines should be substituted for stairways, since 
inclines permit each person ascending them to take such 
steps as suit him; there is consequently less physical strain; 
and the inclines are in many ways more serviceable than the 
stairs. All dry dusting and sweeping must in every school 
be strictly prohibited. In fact, the one thought of every 
architect, builder, and administrator of every school-build- 
ing ought to be that the children are to be looked after first, 
last, and always. Their health and their general welfare are 
to be considered at all times, and everything that is done 
should point principally toward that end. No building is ever 
erected merely for the purpose of giving any teacher, janitor, 
or other person a position on the public pay-roll. And, al- 
though these persons should also be given the best possible 
hygienic conditions, ''Service to Children'' should be the motto 
whenever and wherever a public school is built and maintained. 

The Janitor. — There is one very important factor in the 
care of every schoolhouse and that is the character of the 
work of the janitor. It is useless to talk of school hygiene and 
to construct sanitary buildings unless these buildings are 
to be cared for in the correct way. The importance of the 
janitor's work is often underestimated, and that person him- 
self is all too often not given a fair chance either to know 
what to do or to have the tools with which to do his work as 
it should be done. Some one has suggested that since it is 
thought necessary in these days of classes in domestic economy 
to train homekeepers who have charge of the health of in- 
dividual families, it might also be well to train the men and 



HYGIENIC SCHOOL ENVIRONMENT 295 

women who take care of school-buildings, many of which 
contain hundreds of people where the home usually contains 
but a few individuals. The fact of the matter is that most 
campaigns for better sanitary school conditions begin at the 
wrong place. The first thing to do, in many instances, is 
to see that the man, woman, or boy who daily cleans the 
schoolroom and cares for the rest of the schoolhouse under- 
stands his problem, knows why it is harmful to do dry sweep- 
ing, appreciates the necessity for having plenty of fresh air 
coming into the room all the time, and reaHzes in a general 
way how important his work is. Further, teachers, prin- 
cipals, and superintendent ought to understand the work of 
the janitor. In many cases, if there were a fuller understand- 
ing there would be more sympathy and, consequently, better 
work. Further, school officials should see to it that the janitor 
has all the necessary appliances and arrangements with which 
to do his work. If school health is the first consideration, 
then the means of securing and maintaining that health 
should always be at hand. Cutting down on the amount of 
the janitor's supplies is a poor way to economize if any ef- 
fectual sanitary work is to be done. He should have all the 
appliances that are necessary for him to do his work well. 

All are agreed that it is best to have all persons who care 
for the child's mental development take courses of instruc- 
tion and pass certain examinations. Why would it not be 
well to require courses of instruction and examinations for 
the persons who are to have a very important part in caring 
for the children's physical welfare? Will it be possible to 
secure the best results in school sanitation before some such 
instruction and tests are required of all janitors? In all 
too many cases the janitor owes his position to the fact that 
he belongs to some political faction or that he has some in- 
fluence other than fitness for the work he is appointed to do. 
No other consideration than ability and faithfulness should 
enter into the process of employing and retaining a janitor. 

Further, a good work can be done by any school execu- 



296 EDUCATIONAL HYGIENE 

tive if he will get his janitors together occasionally and dis- 
cuss with them the various matters that have to do with the 
proper care of school buildings. For instance, the subject of 
the proper lighting of schoolrooms could be explained at a 
meeting of the janitorial force. Discussions, illustrations, and 
experiments could be utilized in an effort to get all to under- 
stand the great importance and standard requirements of 
the subject. Other meetings could be called for the consider- 
ation of other problems. A feeling of sympathy between the 
janitors and the school authorities could thus be created 
that would not otherwise exist. The whole situation would 
be materially improved in any school system where such a 
well-planned scheme of bettering sanitary conditions through 
the janitor is undertaken. The janitor's work is of the 
greatest importance. He cannot know too much about his 
work and there cannot be too great an understanding of and 
sympathy with the magnitude of his tasks and the difhculties 
that they present. 

A General View. — In a broad survey of school conditions 
in this country there is to be found much that is hopeful in 
general as well as in the particular phases that have to do 
with school sanitation. Progress in any one school line must 
eventually mean progress in all other lines. Generally speak- 
ing, the most modern methods of teaching are found in the 
most modern buildings. The community that wants good 
teaching generally wants good school-buildings and will get 
them if possible. In sanitary as well as other matters the 
dream of to-day will be the actuality of to-morrow, and we 
shall constantly move on to better things. 

Conclusions. — This introductory survey of sanitary con- 
ditions in the schools throughout the country leads to certain 
general conclusions of a practical nature, namely: 

Practically everywhere in our country there is the spirit 
of progress in matters of school sanitation. 

There is to-day a very much greater expenditure for sani- 
tary measures and appliances than ever before. 



HYGIENIC SCHOOL ENVIRONMENT 297 

City schools spend proportionately more along sanitary 
lines than do country schools. 

As a rule, city school-buildings excel in matters of heat- 
ing, lighting, and ventilation, as well as in several other im- 
portant features. There are many exceptions to this rule, but 
it nevertheless prevails. 

Every school should have plenty of light; plenty of good, 
pure, unbaked, life-giving air; good water; bathing facilities; 
roomy playgrounds; in many instances school-prepared noon 
lunches ; and all other things that go to the making and main- 
taining of health. 

Whenever our people get ready to spend as much money 
on public education and health as on their hogs and cattle, 
and on some of the unnecessary and harmful things in which 
they indulge, there will readily come to pass all the things of 
which we dream. 

The schoolhouse should be the model for the community 
in all sanitary matters. It should be the centre of a radiating 
gospel of good health. 

Finally, the one great opportunity to lay the foundations 
of a superior public health is to be found in the public schools. 



CHAPTER XVII 
SCHOOL SANITATION STANDARDS 

A Sanitary School Environment. — The problem of furnish- 
ing children of a community with a thoroughly hygienic and 
sanitary environment can be seen, in the light of past chapters, 
to be one of great difficulty as well as one of supreme impor- 
tance. Sanitary home and neighborhood conditions are only 
a part of the problem. When we come to the school main- 
tained by the State with compulsory attendance for all chil- 
dren up to a certain age, we have the problem in an acute form. 
The State is not only responsible for the health of its involun- 
tary charges, but it is extremely interested in their hygienic 
welfare. It is, moreover, bound to set as high an ideal of 
sanitation as possible as an example to the public, which has a 
right to take it as a standard. The most sanitary home in the 
country is not too high a standard for the State public school.^ 

Moreover, the problem offers many new difficulties non- 
existent in the ordinary home. The average family is from 
four to six in number, while the average detached house or 
apartment has about the same number of rooms, an average 
of about one to a person. At the school, the average is about 
thirty to forty persons to a room, instead of but one to a room. 
Moreover, these persons are from many different homes and 
sources of possible contagion. In the home, free movement 
about the house is possible; at the school, each pupil leads, for 
the most part, a sedentary life in a seat usually screwed to a 
fixed spot in the room. These and many other considerations 
have led to innumerable grievous sanitary errors on the part 
of school directors, carpenters, and janitors. Their *' apper- 
ceptive basis" has been that of home conditions, and this 

^ See Professor Irving King's recent bulletin on " Hygienic Conditions in 
Iowa Schools," published May 29, 191 5, by the University of Iowa, Iowa City, 
Iowa. 

298 



SCHOOL SANITATION STANDARDS 299 

has been mechanically transferred to the construction and 
sanitation of schools. 

Much if not most of the recent interest and development 
in the field of educational hygiene has been along school- 
sanitation Hnes and a number of the recent flood of books 
indicate this emphasis, one of the best of them devoting about 
fifteen chapters to school sanitation, seven to medical inspec- 
tion, two to the hygiene of instruction, one to physical educa- 
tion, and none to the teaching of hygiene. A large part of 
this interest and development has been brought about by the 
fortunate competition of school engineers, architects, and 
supply houses for the large money rewards in this field. The 
competition of inventive genius and the nation-wide adver- 
tising of sanitary drinking-fountains has, for example, been a 
big factor in this one step of sanitary improvement. Other 
illustrations are innumerable. 

It is manifestly impossible to treat in a few pages or 
chapters of an average book the details of this rapidly develop- 
ing science and practise. We must limit our discussion to 
the barest fundamentals. These fundamentals must and 
should be of the nature of standards or norms by which to 
test and to guide effort in this field. But on looking for such 
standards one must at once be struck with the fact that we 
are practically without real scientific standards of school 
sanitation. We have numerous tentative standards, a lot of 
consensus of opinion and practise, a great deal of dogmatism 
and imitation, but few scientifically established standards. 
The recent investigations of ventilation, for example, have 
destroyed the old opinion-standards of the baleful effects of 
carbon dioxide and lack of oxygen in classrooms, and there is 
a tendency to deride the costly and intricate mechanical ven- 
tilation systems of the present and to rush to open and fresh- 
air rooms and schools. Any observant person in education 
knows of multitudes of expensive school sanitation fads and 
fashions that have come and gone, seeming to benefit princi- 
pally only the fashioners and sellers of the ^'latest thing" to 
unsuspecting school men and boards of education. 



300 EDUCATIONAL HYGIENE 

Undoubtedly great good, as well as much harm, has been 
done by the wide-spread adoption of new opinion-standards. 
The remarkable progress of city school sanitation is due 
largely to this one factor. The unrivalled advance in hospital 
and ofhce-building architecture and sanitation has had, too, 
its more scientific influence. But think of the cost and the 
injury of such methods! Millions for change but not one 
cent for scientific investigation, has been our motto. Word 
goes out from some bureau, book, or self-styled expert that, 
for instance, the lighting of schools should be from the left 
side only, and schools everywhere gradually adopt this norm. 
But the schools of the future, especially small rural schools, 
may some day be changing back to lighting on both sides of 
the classroom, because scientific study may show that the 
shadows of pupils' pencils and hands on their papers are 
not seriously detrimental if at all, or that other features, such 
as more illumination, or cross ventilation in hot weather, are 
of greater hygienic importance. We do not know! It is 
quite possible, at any rate, for a scientific investigation of 
school ventilation problems, such as the Thorndike-Winslow^ 
experimentation now going on, to overthrow many cherished- 
as-absolute standards of the past, and to do a million times 
more real lasting good than many whole State surveys which 
say: "This is bad according to our (opinion) standard 
and your laws must be immediately made to enforce the 
change." 

Being practically without very stable and scientific 
standards, then, we must content ourselves with cautious 
statement, in the briefest terms, of some of the empirically 
derived and established standards now available. They can 
be found scattered in many publications and in evidence 
in many schools in many places. We shall emphasize the 
larger, city school because the rural school problem has two 
chapters devoted to it. In certain cases sanitary standards 
will of course have to be sacrificed for large educational or 

^ See " Some Results of the First Year's Work of the N. Y. State Commis- 
sion on Ventilation," American Journal of Public Healthy Feb., 1915. 

t 



SCHOOL SANITATION STANDARDS 301 

social ends. The centre of a neighborhood, for example, may 
not have as good soil as other locations and yet it may be best 
to choose it, all things considered. 



Tentative School Sanitation Standards 

I. The Site. — (i) Speaking generally, as we must through- 
out, the site should be on rather elevated, porous, uncon- 
taminated soil, preferably gravel and sand. Muddy, wet 
feet and clothing, and foul air rising through the basement 
from a contaminated soil, must be avoided. 

(2) Size. — Ten to twenty acres of good land should be 
made available for consolidated rural schools, two to three 
acres for school and neighborhood playgrounds. Thirty 
square feet of play space for each pupil as a ijiinimum has been 
made a standard by the National Playground Association of 
America. Dresslar is authority for the statement that 
''according to the rules of the London School Board 100 
square feet of play space is required for each pupil. "^ Allow- 
ance must be made for the future extensions of the building 
and for any parking space absolutely required. A full city 
block is a convenient minimum standard. Where blocks are 
as small as 200 feet square, two for each school will frequently 
be standard. 

(3) Surroundings. — The school site must be in a quiet 
place, free from dust, bad odors, and gases, overshadowing 
buildings, and away from sources of ill health or injury to 
pupils. This standard rules out thousands of American 
schools, now located on street-car, automobile, heavy- traffic, 
and even steam-railway streets or lines, or near dusty roads 
or factories, gas-houses, livery barns, planing-mills, saloons and 
other such houses, etc. Foresight and the law must be used 
to protect schools from such dangers to life, nerves, health, 
and sanitation. 

II. The Building. — (i) The building should be arranged 
longitudinally, so classrooms may have unilateral east or west 

^ Portland, Oregon, School Survey, p. 220.^ 



302 EDUCATIONAL HYGIENE 

lighting, the children in the rooms on the west side of the 
building (if of several rooms) facing north and those in rooms 
on the east facing south. 

(2) If possible, the building should be placed at the west 
side of the school site, with the separate heating plant to the 
west of the building. This puts almost the entire playground 
in front of the school building, where it can be supervised to 
some extent from the principal's office (when he cannot get 
out), which should probably be in the middle of the front on 
the second floor. If this part of the building is made to pro- 
ject somewhat, windows may be put into the office to give 
north and south views of the playground also. The Bernard 
Moose School, of Chicago, designed by Dwight L. Perkins, is 
built in this manner. 

(3) The rear of the building to the west, with its separate 
heating plant and smoke-stack, should be made as attractive 
as the front if possible, so the building will not have to '^turn 
its back'' on any neighborhood. 

(4) Practically every school should have a well-lighted 
concrete basement. In smaller schools the heating plant 
will be located here. Great care should be taken to prevent 
the upward movement of moisture in the walls to the school 
walls above. Slate, pitch, and other substances are used to 
cut off this upward movement. 

(5) Arched roofs and steeples are rapidly giving way to 
flat roofs, and very low towers if any, on the larger school 
buildings of four or more rooms. Roof playgrounds should 
be provided where needed. 

(6) Every school building should be as nearly fire-proof 
as possible, and the larger the building the more emphasis 
there should be on this factor. We have lost too many build- 
ings and children by fire. An average of ten school buildings 
burn each week of the year, two each school day. 

(7) The following helpful suggestions for making schools 
fire and panic proof are taken from ^'Fire Protection in Public 
Schools," distributed by the Division of Education, Russell 
Sage Foundation. See also the maps which follow. 




States having 
^ no laws 

FIRE PROTECTION LEGISLATION FOR SCHOOfclOUSES 




Ma Regulation 



LAWS RELATING TO SCHOOLHOUSE CONSTRUCTION IN EACH STATE 

IN 1912 

(From " A Comparative Study of Public School Systems in Forty-Eight States " by the 

Russell Sage Foundation.) 



304 EDUCATIONAL HYGIENE 



STAIR AND EXIT RULE OF NEW YORK CITY* 

(i) All school buildings of two or more stories in height shall 
have at least two stairways. The number and width of stairways 
shall be apportioned as follows: Four feet for the first 50 pupils and 
six inches additional width for each additional 50 pupils. 

Note. — The number of stairways shall be sufficient to permit of 
building being vacated in orderly manner within three minutes from 
sounding of signal. Most fires spread rapidly. Any longer delay 
may result in exits being cut off. 

(2) In estimating number of occupants for each story, an allowance 
shall be made of fifteen square feet of floor space per person per class- 
room. 

(3) Stairs shall not be less than four feet nor more than five feet in 
width between strings. The four-foot width for elementary schools 
is preferable. Width is fixed at four feet to prevent a third line of 
pupils without handrail support. 

(4) There shall be a handrail on each side. 

(5) No closets shall be placed under stairs. Where they exist they 
shall be kept empty and locked. 

(6) All stairs shall be enclosed in wife-glass and steel or other fire- 
proof partitions from top to bottom, access being by means of self- 
closing fire-proof doors. These doors are held open by fusible links. 

(7) There shall be an allowance made of fifteen lineal feet width of 
doorways for the first 500, and six inches additional width for each 100 
additional, persons. These widths should be increased by 50 per cent 
if there be an auditorium on the first floor, or basement which has not 
direct exits. 

IF YOU ARE TO HAVE A NgW SCHOOL BUILDING 

(i) Employ an architect who knows what it means to erect a fire- 
proof building and then 

(2) See that his plans call for: 

{a) Fire-proof construction. 

{h) Building of not more than three, and if possible not more \ 
than two, stories. 

(c) If a large school, each floor constructed with fire-proof parti- 
tions, so that one section may be completely shut off from the rest. 

{d) Heating plant separated from rest of building by fire-proof 
walls, ceilings, and doors. 

{e) Assembly-room on ground floor. 

(/) Attic cut by at least one partition, to prevent draughts. 

^ From a Sage Foundation pamphlet on fire prevention. 



SCHOOL SANITATION STANDARDS 305 

(g) Stairs located at opposite ends of building, and leading di- 
rectly to exits. 

(h) Stairs built according to the "stair rule." (See above.) 

(i) Halls wide, well lighted, and absolutely free from obstructions. 

(/) Outer doors furnished with "panic bolts" which can be opened 
from inside by slight pressure. 

(k) Automatic sprinklers in storeroom and fuel-room. 

And then — 

(3) See that the building is constructed according to the specifi- 
cations. 

IF YOU HAVE AN OLD SCHOOL BUILDING 

(i) Transform stairs into fire-proof exits by following the rule given 
above. See that stairs lead directly to outer doors, even if their 
location has to be changed. 

(2) Make basement ceiling fire-proof. 

(3) Abolish double doors. Substitute single doors, swinging out- 
ward, side by side, and equipped with "panic b^lts." Absolutely 
prohibit fastening of any outside door during school hours. 

(4) See that ashes, waste paper, and other rubbish are placed 
separately in metal, self-closing receivers, and removed from building 
at close of each day. 

(5) See that building is equipped with; 

(a) Automatic fire-alarm. 

(b) Complete system of fire signals. 

(c) Signal connection with fire headquarters. 

(6) Require halls to be kept absolutely free from lockers, tables, 
chairs, and all other obstructions. 

(7) Insist on a fire-drill every two weeks. 

(8) The building must be as free from dust-catchers as 
possible. All interior woodwork should be without unneces- 
sary flutes and grooves. Fluted or beaded ceilings or wain- 
scoting, and much-decorated washboards and blackboard 
frames, are inadmissible. Picture mouldings are recom- 
mended, but they should be devised to catch little dust. 
Dresslar would eliminate them, but they seem desirable for 
non-sanitary reasons. The hospital ideal is not too good for 
the schools. Beauty need not be sacrificed but may be en- 
hanced by thoroughly sanitary construction. 

(9) Corridors may be a standard width of 14 feet in schools 



3o6 EDUCATIONAL HYGIENE 

of several rooms. In the far West a new standard of having 
one-story buildings with classrooms on one side of the cor- 
ridor only is being advocated, and seems desirable for that 
climate in cities that will provide the necessary land space. 
All corridors should be well lighted, should have cement or 
light-colored composition floors, should be unencumbered 
with lockers or wardrobes, and should be provided with 
satisfactory drinking-foun tains, preferably in "batteries" of 
four or more over a narrow trough close to the wall. The 
latter need not be as elaborate and costly as are frequently 
purchased. 

(lo) All other flooring should be sound-proofed and made 
of close-grained hardwood or of rift-sawed pine. As soon as 
laid, the floor should be given, well rubbed in, two coats of 
boiling linseed-oil, in which one pound of paraffin to each 
gallon of oil has been dissolved. This coating closes up and 
protects the wood and provides a vitreous-like surface easily 
cleaned and hard to splinter.^ (See later standards for clean- 
ing.) 

III. The Standard Classroom. Elementary Schools. — 
Standards for elementary classrooms have been gradually 
developed on the basis of present knowledge and theory 
until many of the features have been finally adopted by school 
officials in many parts of the country, especially by State 
boards of education and progressive school architects. Within 
certain Hmits there will remain considerable variation, es- 
pecially as our scientific knowledge of children and of sanita- 
tion increases. The classroom is the centre of the school. 
Here teacher and pupils engage for most of the time in that 
activity for which schools are primarily created. The san- 
itation of the classroom should therefore be as perfect as 
possible. We cannot give here the arguments leading up to 
each feature, nor a discussion of reasonable variations. A 
statement of a desirable norm only is attempted. 

^ See the Springfield, 111., Survey for attention to better specifications and 
better supervision of construction. 



SCHOOL SANITATION STANDARDS 307 

(i) Architects must provide one or more standard class- 
rooms for each school building. The standard classroom is 
the unit of construction. Instead of devising a building of a 
certain size and then putting in classrooms, they must reverse 
the usual process and provide the required number of standard 
classrooms and erect the building about them. With so 
many millions of dollars going each year into new school 
buildings, coupled with the fact that so many old schools are 
burning down, it seems that tliis country should soon ex- 
perimentally develop ideal buildings. Scientific study and 
expert school architects only are lacking to make the most 
of our opportunities, but they are surely, though slowly, 
coming. 

(2) Size. — ^The best size for an elementary classroom 
for about forty pupils seems to be, all matters considered: 
length 32 feet, height 13 feet, width 24 feet. This size has 
in consideration sufficient lighting space, the carrying power 
of voices, distance for seeing and hearing, ease of class man- 
agement and instruction, ventilation, building economy, etc. 
The height may be reduced six inches and the length a foot 
or more, if desired. In high schools the height should be the 
same, but the floor area and shape must be variable.^ 

(3) Lighting. — In standard classrooms the lighting, meas- 
ured in area of window-glass, should be at least one-fifth 
to one-fourth of the area of the floor space. The floor area 
(24 X 32) is 768 square feet. One-fourth of this is 192 square 
feet and one-fifth is 153 square feet. This fighting should 
be from the left side only of the pupils seated, with few ex- 
ceptions later to be mentioned. Windows should reach to 
within five or six inches of the ceiHng — the higher the better, 
since about one-third of the light comes in at the upper fourth 
of the windows. The windows, on the thirteen-foot wall, 
should not reach below a line three and one -half feet above the 
floor; should extend as far toward the rear of the room as 

1 See Dresslar's " School Architecture," published by the U. S. Bureau of 
Education, for valuable data on high schools. 



3o8 EDUCATIONAL HYGIENE 

possible (within eighteen inches) ; should not extend far enough 
forward to throw much light into pupils' eyes; and should 
have the narrowest possible piers or mullions between the 
windows, say one foot as a maximum and these bevelled. 
Round or gothic topped windows should not be permitted. In 
upper grades, the height from the floor may be four feet. This 
leaves an eight and one-half or nine-foot window in length. 
The width of the glass panes may well be about forty-two 
inches and height forty-five inches. Small panes are generally 
less desirable. Starting the windows with the glass of the rear 
window about fifteen or eighteen inches from the rear wall and 
leaving not over twelve inches between windows, glass to 
glass, for mullions and (steel) lintels, with nine-foot windows, 
we find that we can put in ^ye such windows and get a glass 
surface of about one hundred and sixty square feet, leaving 
nine feet of blank wall at the front of the room. Not less 
than six or seven feet should be left a solid wall at the front. 
By reducing the width of windows three inches (to thirty-nine 
inches) six windows may be put in, giving a lighting area of 
about one hundred and seventy-five square feet. The latter 
is probably preferable in most cases. The use of a twelve and 
one-half foot ceiling is economical but makes nine-foot win- 
dows impossible except in primary rooms where the bottoms 
are only three and a half feet from the iioor.^ 

An increase in the width of the windows to four feet has 
been tried successfully in some schools. Such width helps 
to reduce the number of mullions between windows by one, 
and gives a Hghting space of about one hundred and eighty 
square feet with five windows. This is almost ideal, but re- 
quires that the windows be well put in so they may be easily 
handled. This gives also a well-lighted blackboard, but 



^Dresslar recommends this, however, in his "School Hygiene," p. 6i. 
The Sharp-Millar photometer is a good instrument for measuring actual illu- 
mination. Standard : three foot-candles at worst-lighted desk on a cloudy day. 
Dr. Fitz gives a new method of determining lighting values in the Proceedings 
of the Fourth International Congress on School Hygiene. 



SCHOOL SANITATION STANDARDS 309 

teachers should not make a habit of standing near the front, 
window side of the room, in order to keep children from facing 
the light when looking at her. A door into the cloak-room at 
the front of the room on the lighted side makes it impossible 
to place a blackboard in this corner, which is an advantage 
from this point of view. 

It is injurious to the eyes to face windows, both for teachers 
and pupils ; consequently there should be no windows on the 
front wall, and on the rear wall only when it is thought de- 
sirable for ventilation. If the rear wall is an outside wall, 
small windows placed high (eight feet from the floor), with 
their tops on a level with the other windows and with stained 
or other glass not admitting much light, may be used. This 
gives a window the size of the upper sash of the other win- 
dows. These half-windows may, however, be narrower, and 
should be hinged at the bottom and have a spring catch at 
the top. Light from the rear is good for the pupils but not 
for the teacher. 

It is possible to have such windows also on the right side 
of the pupils seated, thus giving light and ventilation into the 
corridor. These may well swing on a pivot and be controlled 
by iron levers. These extra openings are principally for 
ventilation, however, rather than for lighting. I have seen 
such 'transoms" working admirably. 

Windows in rear or right-side walls need not be put in 
merely for the sake of outside decoration. Architects have de- 
vised many ways of beautifying blank walls where there are 
no windows. 

Artificial Lighting. — All classrooms should have arti- 
ficial lighting for use on very dark days and especially for 
evening use. If possible, electricity should always be used, 
and all buildings should be well wired when constructed. 
Gas-pipes should also be installed where gas is available. 
Acetylene lighting has been found satisfactory in rural schools 
where the other forms are unavailable. Much attention 
should be given to the proper placing of the various ceiling 



3IO EDUCATIONAL HYGIENE 

lights and to bringing sufficient light from the proper angle to 
all seats in the room. Where there are six rows of well-placed 
single seats, the front row of ceiling lights, say three in number, 
may be placed a little in front and to the left of the first desk 
near the window, the third desk from the window, and the 
fifth. The second row may be over the first, third, and fifth 
desks in the third cross row of seats, while the third row may 
be placed similarly just back of the fifth row.^ 

Window-Shades. — Most window-shades in schools are ob- 
jectionable, either because they are not translucent and so 
cut off too much light when down, or they are hard to manage, 
or they cannot be adjusted to diminish only the light which 
is too bright for the pupils' eyes. The Draper and other 
window-shades can be easily adjusted to cut out light where 
desired, and the plan of having the curtain roll at the bottom 
instead of the top, or of having two rolls at the middle, is 
to be commended. Ecru or light-tan color has been highly 
recommended. Dark green should be avoided. Light green 
or light gray may be used to harmonize with wall colors. The 
ideal is to get plenty of light without cutting off too much 
and without allowing the direct rays of the sun to fall on the 
pupils' work.2 

Wall Colors. — ^AU walls should be smooth but not glossy, 
and painted with washable flat paint in light tans, light 
greens, Hght buffs, or light grays. A cement dado should take 
the place of the ordinary wooden wainscoting, and may be 
painted a darker color than the walls above. The ceiling may 
be nearly white in color. Great differences in light can be 
made by giving care to wall colors. In corridors, more white 
can be used without injury to pupils' eyes, and white tiling 
for the first four or five feet above the floor is desirable. 



* See Dresslar's "School Hygiene," p. 78. 

^ Doctor Ayres found in the Springfield, 111., Survey that the illumination 
was kept below the standard of three foot-candles even on bright days, because 
teachers did not properly adjust the shades, and that windows covered with 
dirt and coal-soot cut off in some cases 50 per cent of the light. 



SCHOOL SANITATION STANDARDS 311 

Blackboards absorb much light but can easily be covered by 
curtains, matching the wall color, which can be pulled down 
when blackboards are not in use. Such curtains function 
also in keeping work that the teacher puts on at intermission 
from the children's gaze until they are ready to work on it. 
Sliding blackboards have been invented. 

(4) Heating. — The standards for heating one or two room 
buildings are discussed in other chapters. The proper tem- 
perature for classrooms in this country is from 65 to 68 
degrees. Rooms should be allowed to go above 70 degrees 
only on cold mornings while the building is being heated up. 
The air should be about half -saturated with moisture, say 55 
per cent. No dogmatic and general standards can be made 
here for all sections of a great country like America, and for 
schools of all sizes from one to a hundred rooms. Hot-air 
furnaces for small schools of two to six rooms are in some 
cases desirable, especially in the places where there are mild 
winters. Hot-water heating has many advantages, but is 
slow, and not desirable for the more northern schools, perhaps. 
Steam-heating is growing in favo^ in all of the larger schools. 
It works well with a fan (plenum or exhaust or both) system 
of ventilation. When we have the air entering the rooms 
slightly heated and the air heated indirectly by radiators also, 
we have what is called the very common and desirable ''di- 
rect-indirect" method of heating schools. 

(5) Ventilation. — ^The problem of furnishing 40 or more 
children, seated for hours at a time in a single room contain- 
ing less than 10,000 cubic feet of space, with a sufficient 
amount of fresh warm air without draughts is one of the most 
serious problems of school sanitation. Two movements tend 
to disturb our standards in this field at the present time: 
The open-air-school movement has brought a great emphasis 
on obtaining outdoor conditions without great discomfort, 
and a wide-spread discontent with current methods of ven- 
tilation. Secondly, the numerous scientific studies and ex- 
periments of recent years have fairly well proved that it is 



312 EDUCATIONAL HYGIENE 

not the lack of oxygen, or the excess of carbon dioxide or of 
organic particles that makes schoolroom air unfit to breathe, 
but that it is improper temperature, lack of variation in 
temperature and movement of the air, and lack of humidity 
that cause the bad effects. These two beliefs have led to two 
principal applications : furnish less heat and make classrooms 
into fresh or open air rooms, and, second, make classrooms 
into closed-air rooms, and by the use of return ducts and 
careful air- washing and humidifying return all air to the class- 
rooms, thus making it recirculate over and over again. 

Not counting the initial costs of any changes in windows 
or the purchase of bags for the children to sit in in cold 
weather the open-air room is evidently more economical 
than the fan system, saving very much in the way of coal. 
Likewise, overlooking the cost of return ducts, air-washers, 
and closing up of cracks, the recirculation of the air for given 
lengths of time is very much more economical than the pres- 
ent systems, which heat up a lot of air and then force it out 
almost immediately in the effort to get proper ventilation. 
Experiments made at Springfield, Massachusetts, and else- 
where indicate a saving of about 40 per cent in fuel. The 
air is cleaned, made moist, and is used for a half-day or so at a 
time without change. It is claimed that the air is unobjec- 
tionable by this method and that it is even better than the 
outside air, being free from dust. By bringing such air into 
the rooms near the pupils' faces, as in the Minnesota experi- 
ment,^ and by varying the velocity occasionally, coupled with 
arrangements by which rooms are occasionally flushed with 
fresh outdoor air, it seems that we have here the beginnings 
of an economical method quite different from the one so long 
employed where we have tried to heat up and push through 
schoolrooms and on outdoors 2,000 cubic feet per minute 
per classroom. We must await further experiments and tests 

^ See address by Professor Bass in the Proceedings of the Fourth Interna- 
tional School Hygiene Congress, also addresses by McCurdy, Gulick, and others. 
See also articles by Kimball and Winslow in Science for April 30, 1915. 



SCHOOL SANITATION STANDARDS 313 

along this line. Perhaps the open-air method can in the 
future be employed in mild and warm weather and the re- 
circulation device utilized in cold weather.^ 

Open-Air Rooms. — ^Another chapter deals with open-air 
rooms and schools. The proper construction of windows for 
such rooms is still in the experimental stage, although such 
bodies as the Boston Schoolhouse Commission and others 
have given the matter much study and have succeeded 
fairly well. The Oakland School-Building Inquiry recom- 
mended that ''in each new building there shall be at least one 
open-air schoolroom that cannot be entirely closed, preferably 
opening to the east. In all new buildings there shall be pro- 
vision made whereby every classroom may be easily trans- 
formed into an open-air room, such transforming measures not 
to be under the control of teachers and pupils." 

One plan that has seemed to work has been that of making 
the entire window in one sash and hinging this at the top so 
it can be pulled inward and upward by a strong cord and 
fastened. Many other plans are being used. 

Common Methods of Ventilation. — Three common methods 
of ventilation are in vogue: window ventilation, gravity ven- 
tilation, and mechanical ventilation. Most schools of our 
country use the first method but with notoriously poor re- 
sults. Little attention is paid to ventilation in most homes, 
since there are so few persons to a room, sinte all are free to 
move about, and since enough air frequently slips in at cracks 
and through walls to supply fairly well the needs of ventila- 
tion, although there is probably also a great lack of proper 
ventilation in many homes, especially in sleeping-rooms. 
Most schools have in the past been provided with as little 
means of proper ventilation as most homes, but the conditions 
are entirely different, especially in the great number of per- 

1 See chapter on the "Physiology of Ventilation" in Terman's "The Hygi- 
ene of the School Child," Hill's pamphlet on "The Relation of the Atmosphere 
to Our Health," published by the Smithsonian Institution, Washington, D. C, 
and Kimball's articles in the School Board Journal for 1914-15. 



314 EDUCATIONAL HYGIENE 

sons from different families that are here collected together 
to remain relatively fixed in stationary seats. Teachers are 
typically young women without a professional education and 
with little training or knowledge of ventilation needs and 
devices. They must study and be trained along these lines. 

Window Methods. — ^Windows should be opened and the 
rooms flushed out with outdoor air at all recesses and inter- 
missions. Further, teachers and pupils need not be afraid of 
fresh air in classrooms. By keeping on more clothing than in 
a seventy-degree atmosphere teachers and pupils can easily 
and quickly accustom themselves to almost outdoor con- 
ditions even in cold weather. They usually profit by it, be- 
coming enthusiastic champions of fresh air. Draughts should 
be avoided when they strike directly on pupils. Window- 
boards six inches in width and the width of the window in 
length may be placed beneath the window in such a way as 
completely to close up the space at the bottom of the window 
but leave a space between the sashes in the middle of the win- 
dow where the air will come in when it is colder outside than 
inside, without a draught on any pupil. Such boards are awk- 
ward to remove unless they are cut into and hinged in the 
middle. Any boy can make one for each window in a short 
time or, better still, a group of boys can make them co-opera- 
tively. If too much light is cut out by this method, upward 
and inward slanting glass deflectors may be used. Dresslar de- 
scribes three kinds in his article on "Ventilation" in Monroe's 
*' Cyclopedia of Education," volume five. Teachers should 
study the matter even where they have gravity systems of 
ventilation. If in the middle of a period the room gets foul, 
the children may be given calisthenics or marching, or may be 
sent to run around the house once or twice, while the room is 
being flushed. The teacher must cultivate a sensitive nose for 
bad air and remember at all times that the tendency is to get 
gradually accustomed to poorer air as a period goes forward. 

Gravity Systems. — Differences in weight of warm and cold 
air make possible in cold weather, when windows cannot well 



SCHOOL SANITATION STANDARDS 315 

be opened without draughts and heat-expense, systems known 
as gravity systems. They are generally not efficient enough 
for schools except in the coldest weather, but must be used 
in all small schools where forced, mechanical draughts are out 
of the question because of the expense. The jacketed stove 
has been described in the chapter on ''Rural School Sanita- 
tion" by Mr. Monahan. Heat within the jacket and heat 
in the chimney about the aspirating or outlet duct for foul 
air causes the air to rise and spread in the room and to be 
forced out by the colder air coming from without through a 
flue passing under the floor to a vent within the jacket of the 
stove. Care must be taken to insure that the fresh air brought 
in is not that from under the building and that the opening 
to the outside is covered with a screen. 

The hot-air furnace is another gravity S3^stem. The fur- 
nace is usually placed beneath the floor in the basement and 
has a flue bringing in outside air and other flues or pipes 
taking the air up to the room or rooms. The fresh air coming 
from the furnace should enter the room on an inside wall if 
possible and about eight feet from the floor. All persons 
putting in such devices should get expert advice from either 
the State department of education located in the capital city 
or from the United States Bureau of Education at Washing- 
ton. This applies to most sanitary features, especially to the 
plans and construction of the school itself, and is about the 
most valuable recommendation of this entire chapter. Get 
expert advice and save for years to come not only the money 
of the community but its comfort and health. 

Mechanical Systems of Ventilation. — This plan does not 
depend upon gravity alone but puts a fan into the system to 
force the air into the rooms, the plenum system; and fre- 
quently adds to this in large buildings another fan near the 
top of the building to blow the air out, the vacuum or exhaust 
system. Where the upper fan is omitted, a feature of the 
gravity system is sometimes added in the form of small steam 
coils in the foul-air flues to heat the outgoing air and make it 



3l6 EDUCATIONAL HYGIENE 

rise faster. Generally the plenum fan or blower in the base- 
ment is sufficient. 

Accepted standards for such ventilation require at least 
thirty cubic feet of air for each person in the room per minute. 
The air should enter the room at a height of eight feet above 
the floor through a vent about two feet square. If a grating 
is placed over this inlet it should be of such small cross-bars 
as not seriously to retard the air. It should also have de- 
flectors attached to throw the air upward and toward all 
parts of the room. The speed of the entering air should 
not be more than 400 feet a minute as measured by the 
anemometer (a small fan wheel connected with a clock-like 
recording arrangement to measure velocity). The ducts to 
each room of forty pupils should be at least four feet square 
in cross-section, so as to keep the velocity within them down 
below 600 feet a minute. The entrance duct may be at the 
front of the room and the outlet duct (four square feet in area) 
at the floor in the same wall, with another outlet six to eight 
feet above the floor in the cloak-room behind the front wall of 
the classroom. The air can be made to reach the cloak-room 
by placing openings in the bottom of the doors leading from 
the classroom to the cloak-room. Such an arrangement 
helps to dry and aerify the clothing. Long hooks far enough 
apart should be used to keep the clothing from contact, and 
open for drying and aeration. This cloak-room should be 
about six feet in width and should have no door leading into 
the corridor. A large window should light it well, and drip- 
troughs for umbrellas and pigeonholes for overshoes should 
be provided. 

The fan or blower in the basement should be noiseless and 
should be large enough to provide an ounce of pressure without 
running more than three hundred revolutions per minute.* 
The fresh air should be taken from a point where there is little 
dust or smoke, which in cities is usuafly high in the air above 
the roof. If the air is still dusty or smoky it should be washed 

* Professor Caswell Ellis in the School Board Journal for September, 1913. 



SCHOOL SANITATION STANDARDS 317 

before entering the rooms. Numerous devices for air-wash- 
ing have been devised, about the best at present providing 
for passing the air through a stream or ''rain'' of water 
dropping from small holes in a pipe across the passage. Pro- 
fessor Whipple, of Harvard, has made a number of very valu- 
able experiments in this field. Such an arrangement if properly 
put in may provide sufficient humidity to the warmed air also. 
The standard for humidity is about 55 per cent saturation.^ 
Steam pans, as in the Horace Mann School, Columbia Uni- 
versity, work very well as humidifiers if large and well regu- 
lated by automatic devices controlling both temperature and 
amount of moisture, but do not clean the air appreciably. A 
great fault with most such systems is that janitors persist- 
ently overheat ("cook") the air. It is doubtful if the air 
should ever be hotter than 65 degrees Fahrenheit in the fan- 
room of the basement, and very little warmer when it enters 
the rooms. The radiators principally should be depended on 
for heat. The air should be kept as cool as possible consistent 
with comfort. Provision should be made whereby the air may 
be shunted at times into the ducts without passing through 
the heat coils across the entrance to the fan-room, thus mak- 
ing it possible to get fresh outdoor air at physical training 
or other periods. In the writer's own experiments a hinged 
screen was thrown in front of the coils and a door at the side 
opened into the fan-room to let the fresh air directly into the 
fan. 

The air velocity of all rooms should be measured once or 
twice a year or whenever a room seems to be getting too much 
or too little air. The supervisor of hygiene may do this or 
teach principals how to do it. The velocity of the incoming 
air should be taken as the average of several measurements at 

1 The sling psychrometer, or hygrometer, especially the one made by Max 
Kohl, is a good instrument for measuring the percentages of moistures. Tables 
must be used, however, to calculate the amount. The best simple instrument 
which dispenses with calculation and can be read directly is the hair hygrom- 
eter, as easily read by a teacher or pupil as a clock. (Made by the Central 
Scientific Co., Chicago.) 



3l8 EDUCATIONAL HYGIENE 

several points on the four-square-foot surface of the mouth of 
the duct. This average velocity for the whole area should be 
multiplied by the area in square feet to get the quantity 
entering for a given length of time, say thirty seconds. This 
product divided by the number of pupils and teachers in the 
room will give the average amount coming in for each person. 

(6) Blackboards. — ^Blackboards should be of slate, al- 
though glass and composition boards are being slowly per- 
fected. In the standard classroom, blackboards will be 
placed on the rear, right, and front walls. They must be 
written on by both teacher and pupils and should conse- 
quently be wide enough to meet the needs of both. The 
front board may well be 5^ feet wide, the others 4 feet, or 
perhaps 3^ feet, to avoid as much light-absorption as possible. 
In primary rooms the bottoms of the boards should be not 
higher than about 26 inches from the floor, and in upper 
grades and high school about 30 to 38 inches above the floor. 
The increase in height may be graded between these ex- 
tremes. Hard, dustless chalk should be used, and wire 
hinged screens should cover chalk troughs. Curtains on rollers 
of a light color may be used, as suggested, to cover boards 
when not in use, in order to prevent light-absorption. Soft, 
dustless erasers should be used and these should be cleaned 
once a week or of tener by the janitor or other persons. Where 
there is a vacuum-cleaning system, erasers furnish no problem. 
Dresslar in his ^^ School Hygiene" gives several good sugges- 
tions along this line. 

(7) Water. — Some have set the standard of hot and cold 
running water in a fixed bowl in every classroom or cloak- 
room, and certainly this will come in all of the most sanitary 
schools. Pupils need plenty of water to drink and they need 
to keep clean. Drawing and other forms of work require 
water and some forms make pupils dirty enough to require 
washing. Where the basin is located in the cloak-room the 
floor may be made of the same composition as that of the 
corridors — cement, tile, asphalt, or composition. The cold- 
water faucet should be equipped with a sanitary drinking- 



SCHOOL SANITATION STANDARDS 319 

fountain. Rural schools may now have drinking-fountains, 
as shown in another chapter. Common cups and individual 
cups should go. Common towels should also disappear like the 
old feather duster. Paper towels are now cheap and efficient 
enough to be provided all children. Real sanitary habits can- 
not come without them. Soap may be suppKed in liquid 
form from automatic containers. Health habits cannot be 
developed with no opportunity to practise health acts. Anti- 
Typhoid Mary habits come with exercise. 

(8) School Desks. — School desks are in a transitional 
stage also. They should provide for different types of work 
than formerly, e. g., manual training; they must be individual; 
they must be adjustable, seat and desk; they should be thor- 
oughly sanitary (neither dust-catchers nor hard to clean under) ; 
the tops should be adjustable for writing, read^g, and manual 
work; and many are now demanding that they be movable 
on the floor. The Moulthrop school chair, a combined seat 
and desk, is about the best type that at the present meets 
the last and several other of the standards. The top can be 
tilted to hold a book while a pupil is reading or singing, and 
it can be moved forward and backward and up and down. 
The seat part is not yet made adjustable but is made in dif- 
ferent sizes. These chairs can be moved by pupils to any 
part of the room, as the teacher or janitor wishes. 

For a seat screwed to the floor, as few legs to interfere 
with sweeping and cleaning as possible should be provided — 
one for each pupil, instead of four to six, as is customary, if 
possible. The single-pedestal combined desk and seat meets 
this requirement well, the base being a large oval (front and 
back), closed iron standard. Such desks must be well put 
down to avoid wiggling by the pupil on the seat in front. 

Dresslar gives twenty-one excellent standards for school 
desks in Monroe's ''Cyclopedia of Education," which should 
be observed in every schoolhouse. 

IV. Cleaning and Sanitation. — Cleanliness is the first 
principle of sanitation. Since most diseases are caused by 
germs and since these are best eradicated by cleanHness, we 



320 EDUCATIONAL HYGrENE 

have a fundamental law of school sanitation: Keep every- 
thing as dean as possible. First, we must have clean chil- 
dren with clean clothing and clean and filled teeth. This 
requires tactful work on the part of school-teachers and 
nurses, and co-operation on the part of parents. There must 
inevitably be provided in many places school baths and free 
school dentistry. Habits of personal cleanliness at the school 
must be inculcated persistently, such as cleaning' the feet 
thoroughly on mats and scrapers provided, before entering 
the school, using a handkerchief (some teachers and nurses 
have used handkerchief as well as tooth-brush drills), bathing 
at least once a week, washing thoroughly before coming to 
school and at school when necessary, etc. Hot and cold 
water in stationary bowls for washing, paper towels, and liquid 
soap are requisites, especially in toilet-rooms. Second, the 
school must be in a clean location with clean air, walks, and 
yards. Third, the janitor must be trained to do his work in 
the best way. Feather dusters and dry sweeping should be 
abolished. Vacuum cleaning should be provided wherever 
possible. Floors should be oiled with a light oil several times 
during the year, thoroughly rubbed in and then carefully 
wiped off. Where there are no vacuum cleaners, oiled-hair 
filter brushes should be used instead of brooms. Every 
janitor and teacher should know how to make damp or oiled 
sawdust for sweeping, and teachers should demand that such 
a sweeping compound be used to keep down dust. Dusting 
should be done with a damp or oiled cloth, never with a dry 
cloth or feather duster. All floors should be swept daily 
and windows should be washed often enough to keep them 
clean, at least three times a year. Blackboards should be 
washed once a week. Toilet seats should be scrubbed daily. 
Floors should be scrubbed frequently if they are not oiled. 
Strange to say, floors may be scrubbed with oil and the 
floors kept fairly white and clean after years of oiling. As a 
principal I once had the teachers vote on the oiling or scrub- 
bing of floors. They voted for scrubbing without the use of 



SCHOOL SANITATION STANDARDS 32 1 

oil, but in a month or two voted in again the use of oil. The 
janitor knew how to put it on and how to remove the part 
not absorbed by the wood, so skirts were little injured. The 
oil kept down the dust and kept the floor from wearing. 

Third, the promiscuous use of pencils should be abso- 
lutely prohibited. One or two outbreaks of diphtheria and 
other diseases have been definitely traced to this pernicious 
custom this year. It is hoped that medical supervision will 
permanently kill this practise. If possible, pencils should 
never be collected together, not even in numbered recep- 
tacles, and pupils should be taught to avoid putting into their 
mouths the pencils of others or anything else another person 
has had in his mouth or possession, with few exceptions. 
School-books are not put into the mouth very much but 
should probably be sterilized occasionally \^ heated moist 
air. Rules along this line can be worked out by the super- 
visors of hygiene.^ 

V. Sanitation of Special Rooms and Features. — The above 
principles apply fairly well to all rooms. Toilets furnish a 
perpetual problem in this respect. Some of the newer build- 
ings of Chicago and other cities have developed the tower 
construction for toilets, one toilet on each floor for both sexes, 
for pupils and for teachers. The towers provide separate 
ventilation and privacy, and seem a desirable invention. 
Many of our best city schools are taking the standard of a 
toilet-room for both sexes in connection with each class-room, 
so teachers may have better control, and so the usual mixture 
of all children from all rooms will not need to congregate to- 
gether. The best practical plan for most schools at present is 
to have dry, well-lighted, and ventilated basements for the 
large toilet-rooms and to have smaller ones of one stool each 
on each floor for both sexes. Separate exhaust fans for 
toilets are necessary in large buildings. 

The number of toilet seats needed is standardized at 

* See " Man and the Microbe/' by Winslow, in the Popular Science Monthly 
for July, 1 9 14. 



322 EDUCATIONAL HYGIENE 

about one for each fifteen girls and one for about each twenty- 
five boys. One urinal stall for each thirty boys will be found 
sufiicient, if the younger pupils are dismissed earlier than the 
older and the janitor supervises the toilet-room. 

The One-Story, Top-Lighted School. — ^After a number 
of years the writer has come to the conclusion that wherever 
it is possible to secure sufficient land for a site, the ideal 
school, all things considered, is the one-story, top-hghted 
school. It is especially to be recommended for consohdated 
schools. The building may be constructed of concrete and 
have a single row of classrooms somewhat in the shape of a 
capital U with a middle extension for auditorium and gym- 
nasium, making it more like a capital E. The inside of the E 
on the classroom wings may be flanked by a corridor which 
may be enclosed in glass in winter. The right side of each 
room above the blackboard may have the windows suggested 
above, as well as the rear, in certain cases, for ventilation pur- 
poses. The left may well be Hghted as suggested above; and 
there may be a door from each classroom opening outward to 
the corridor on the right, and also to the playground at the 
left of the pupils as seated. 

There may well be added the "saw-tooth plan," or other, 
of overhead lighting, under full control of the teacher, which 
will give plenty of light and sunshine to the room and make it 
possible to reverse the dimensions previously given (24X32) 
to a width of about thirty-two and a length of twenty-four. 
Such a room brings the pupils forward nearer the teacher, 
gives a longer front blackboard, gives two compact groups, 
right and left, for instruction instead of two or three long 
rows of children, and has other advantages. 

The advantages of the one-story building are too numerous 
to mention here. The reader is referred to the editor's volume 
on the 'Consolidated Rural School," and to the June, 1918, 
number of the American Journal of School Hygiene, Worcester, 
Mass., and to several articles by the editor in The School Board 
Journal in 19 18-19. 



III. THE HYGIENE OF INSTRUCTION 

CHAPTER XVIII 
THE GENERAL HYGIENE OF INSTRUCTION 

The Problem.^— In its application to the instruction of 
children, hygiene takes on a wider significance, if possible, 
than it does in any of its other special phases. In looking to 
prevention of immediate physical injury it is negative, in 
its care for future physical development it is positive in its 
view-point; but in addition it must concern itself with sim- 
ilar problems, negative and positive, with regard to mental 
health and development. It must study both the objective 
and the subjective results of school life. Therefore, while 
busied with the problem of providing conditions that make 
for such characteristics as strong muscles, deep breathing, 
erect posture, and clear vision, it must have an "ear to the 
ground," so to speak, for any condition that may lead to faulty 
habits of attention and association, hinder the development 
of good memory, or in any way interfere with the develop- 
ment or cultivation of the power to think clearly. Even the 
emotions must be considered, so that it devolves upon hygiene 
to consider the attitudes, healthful and otherwise, that are 
related to or that result from the child's experience in school. 
It is this broad, or, if you please, this multiple, view-point 
that determines what are the problems and what the methods 
of their solution in the hygiene of instruction, or, as it is 
termed by the editor, the hygiene of methods of teaching and 
management. 

It has been pointed out that our army of school-children 
in this country is now some eighteen to twenty millions strong 
and that throughout the greater part of the year about half 
the waking time of these young recruits is spent in school. 

323 



324 EDUCATIONAL HYGIENE 

They are there to receive instruction. It is for the same 
purpose that teachers are hired and that buildings and 
grounds are provided and equipped and maintained in -every 
State. ( 

Now, the fundamental principle of instruction is that the 
organism of the child is immature, is still developing, and 
that by imposing certain conditions we are able to influence, 
to modify, and to mould his physical and mental development. 
Instruction, therefore, touches his life at its most vital points. 

But let us not forget that the child's response to bad may 
be as ready as that to good instruction. Bad environment or 
faulty methods may initiate abnormalities of development. 
This is especially true of the mental development of children 
who have inherited or acquired tendencies toward neuroses. 

In the light of such facts, the importance of making the 
instruction of this army of future citizens hygienic looms 
large beyond our powers of comprehension. We are intro- 
duced here to problems that reach nation-wide and soul-deep. 
They are of vital importance to the domestic happiness and 
the prosperity of millions of future homes, and they relate 
themselves to a great extent to the economic welfare of every 
State. 

Instruction is a general term and may be concerned with 
a wide range of activities, physical, mental, or both. A 
rigid classification and detailed treatment of these is out of 
the question here; I shall therefore only attempt to summar- 
ize the more important principles involved and give some of 
their applications, taking up first those of a more general 
nature and following with those that concern themselves 
more particularly with mental hygiene. It should be stated 
that in doing this I draw heavily from both published and 
unpubHshed material of Doctor Wm. H. Burnham, of Clark 
University, as well as from notes taken in his courses of 
lectures. Indeed, those paragraphs which deal more specific- 
ally with the characteristics of mental health do little more 
than to summarize his contributions in this field. 



the general hygiene of instruction 325 

General Hygiene 

Innate Ability. — Extended investigations have clearly de- 
monstrated that children are not all equal with respect to 
their abilities along certain lines. Especially is this true in 
case of those mental powers upon which so much of the or- 
dinary school instruction depends. Hygiene of instruction 
demands that this be recognized and that requirements be 
adapted to the abilities and individualities of the children. 

Some children are mentally defective; they should be 
placed at once in special classes and receive special instruc- 
tion by special methods. Some are merely slow in their 
development, constituting the type known as "retarded"; 
these, too, should be placed in special classes and given indi- 
vidual attention. With a little care they cai\ without injury, 
be brought up to the average, in course of time. On the 
other hand, to attempt to drive such pupils through their 
classes at the same pace and in company with their more 
developed comrades of equal age is in many cases merely to 
transform retardation into arrest. 

Again, many a child is so unfortunate as to have inherited 
an unstable nervous system and thus have within him a strong 
tendency toward the development of some form of neurosis. 
Usually this is shown by such characteristics as nervousness, 
inability to sit still, and lack of motor control. Hygiene would 
demand that in such cases special care be taken to avoid 
overstrain from heavy work and that no tasks be given de- 
manding strained attention for lengthy periods. Better to 
modify the instruction than to run the risk of throwing the 
nervous organization out of balance, perhaps for life. 

Similarly, the unusually gifted pupil should receive some 
special consideration. Holding such a pupil to cons.tant repe- 
tition of well-known and easy tasks that require no effort may 
lead to loss of interest, inattention, dawdling, and even fail- 
ure. An otherwise specially promising pupil is thus trans- 
formed into a repeater and a dullard. 



326 EDUCATIONAL HYGIENE 

Stage of Development. — ^The fitting of instruction to the 
stage of the child's development, physical and mental, is of 
significance for hygiene. 

Length of life cannot be depended upon as a measure of 
the advancement a child has made in his development. Girls 
are some two years ahead of boys in their development at 
the time of puberty, and progress .more rapidly to maturity. 
Even among children of the same sex, variations are great. 
Phenomena of growth, pubescence," skeletal ossification, den- 
tition — all these give evidence that the rapidity with which 
children approach maturity varies widely from individual to 
individual. The degree of relationship between these and the 
development of mental power has not been entirely worked 
out. A correlation is suggested, however, by such investiga- 
tions as those of Porter, Smedley, and Crampton, in America, 
and of Grazianoff , Sack, Quirsfeld, and Riez, in Germany, all of 
whom found a close relationship between various phases of 
physical health and development on the one hand and either 
school success or mental power on the other. 

As has often been pointed out, it is clear that there is a 
pedagogical and hygienic moral to be drawn from these facts, 
namely, that grading for educational or other purposes on the 
basis of chronological age, i. e., age in years alone, is en- 
tirely inadequate. Doctor Crampton has demonstrated how" 
true this is for pubescent boys. We may therefore state as a 
hygienic principle that grading, implying, as it does, a measure- 
ment of the amount and kind of work that may properly be 
required of a pupil, should be based upon the mental and 
physical powers to which he has attained at a given stage of 
development, regardless of what his age in years may be. 

This principle becomes especially significant when applied 
to school beginners. As I have shown elsewhere, there is 
much evidence in support of the theory that a transition or 
"nodahty" in general development occurs at about this time. 
This is indicated by a number of phenomena, such as varia- 
tions in growth, second dentition, change of growth rate in 



THE GENERAL HYGIENE OF INSTRUCTION 327 

certain organs, and acquisitions of certain neuro-muscular 
and psychical powers. These do not occur in all children 
at a given age. Variations are great, as is well illustrated by 
skeletal ossification and by dentition. 

The exact relationship of these phenomena to each other 
and to general development is not known, much less their 
relationship to mentality. But, however that may be, the 
fact that so many fundamental developmental changes occur 
at this period of Kfe is sufficient basis for the demand that, 
until it is past, any instruction other than that partaking of 
the nature of free play and allowing for natural reactions and 
normal physical development should probably not be given. 
The hygiene of instruction up to the age of seven or eight 
years is distinctly the hygiene of general health and normal 
development. Moreover, there are many ijidications that 
those children who do not begin formal school work until 
about the eighth year are not only not handicapped but are 
rather benefited thereby in the long run. The interesting 
and accumulating data concerning certain precocious children 
who at a very early age gained remarkable command of cer- 
tain forms of school knowledge have seemed to some to point 
in the opposite direction, but this is doubtful, to say the least. 

So much for the general statement. But, again, the above 
facts justify the demand that when the time for school work 
does arrive, entrance be based not upon the mere age in years, 
but upon the degree of physical and mental development. 

We hear much in these days about "repeaters." And 
truly our instruction is not hygienic when we have a high 
percentage of pupils in all our schools droning over again the 
work of last year. But, bearing in mind the great variation 
in development at this period, and also the general relation- 
ship between physical and mental development, it must follow 
that very many of the problems of ''repeaters" in the grades 
would never be met if children were admitted to the first 
grades only on the basis of their fitness as indicated by stage 
of development. 



328 EDUCATIONAL HYGIENE 

Properly, grading should take into consideration at least 
those special phases of development that have been mentioned 
and possibly some others also. It must be admitted that no 
standards for such grading have been established. In view of 
their absence, and also in view of the fact that dentition is 
so closely related to development as a whole and to nutrition 
in particular, there is much to be said in favor of taking that 
as an index. Unless otherwise exceptionally well developed, 
there is, hygienically, some question as to whether a child 
who has not erupted his first permanent molars should begin 
formal school work. 

Differences in the development of the sexes must be 
considered. At the period of life when school work is usually 
begun, girls are relatively more advanced than boys of equal 
age. The difference between them grows progressively 
greater up to the time of maturity, being especially significant 
during the pubertal years. This being true, the question is 
raised as to whether the instruction of the sexes should be 
the same from the beginning, but sufficient data are not yet 
available upon which to base a definite answer. On the 
other hand, the difference between the sexes at the pubertal 
period is so evident and so great that a differentiation of in- 
struction becomes not only a hygienic but a pedagogical de- 
mand also. 

Knowledge of mental development is not sufficiently ac- 
curate to admit of a close grading. Some facts of a general 
nature are known, however, a few of which relate themselves 
to our topic and may here be mentioned. 

Much of present-day classroom procedure very easily 
approximates a reaction-time experiment. That is, the child 
is given a question to which he must reply in the briefest 
possible time. This is fundamentally wrong. It has been 
demonstrated experimentally that the child's mind reacts 
much more slowly than that of the adult, as shown by the 
greater length of time it takes him to make associations of 
ideas. Quick replies should therefore be neither required 



THE GENERAL HYGIENE OF INSTRUCTION 329 

nor expected from young children, especially when the ma- 
terial with which they deal is new and unfamiHar or difficult. 

Questions should be clearly and definitely stated, and then 
a reasonable time for answer should be given, with some re- 
gard, of course, for individual differences of pupils. Driving 
the child to answer too rapidly is Hable to result in habits of 
carelessness and inaccuracy, establishment of wrong reac- 
tions that may persist and impede thinking in the future, 
discouragement on account of failure, nervousness, and over- 
strain, or a combination of these. In any case, the result is 
liable to be detrimental to development of clear thinking 
and good mental power. In the early school years, drill for 
speed should only follow the mastery of the proper associations. 
When proper associations are firmly established, drill for speed 
is in place. 

Again, the mental imagery of the chilci up to about the 
pubertal period is concrete rather than abstract. This is 
the normal condition; and instruction, to be hygienic, should 
take account of the fact. Power of abstract reasoning de- 
velops late — at least as late as the adolescent years. Stimu- 
lation to this kind of activity at too early an age is liable to 
cause premature development or overstrain, either of which 
is injurious and should be guarded against. 

Doctor Hall's early investigation showed that a high per- 
centage of children begin school remarkably poor in ideas 
gained from experience. A number of other investigations 
have since confirmed his results. Too often the school gives 
no opportunity to make up for this deficiency and the result 
is that pupils become drilled in a ^'word education" and lack 
the power either to think clearly or deal intelligently with a 
concrete situation requiring tact and mental power. Hygiene 
has an interest in developing healthy mental powers as well 
as preventing injury. The meaning of all this is, therefore, 
that during his early years the child in the grades should be 
put into possession of a wealth of concrete ideas and of the 
abiHty to use them, not introduced — much less driven — to 



330 EDUCATIONAL HYGIENE 

the working out of complicated, abstract problems like some 
that have found their way into our arithmetics, where the es- 
sential thing is a logical trick. 

The span of attention is more limited in the child than in 
the adult. Also, the span for immediate memory is shorter 
in the earHer years than later in life. That is, the quantity 
of material that can be held in mind for immediate repro- 
duction is considerably less. The child often does not un- 
derstand a long sentence, even though it be presented in 
simple terms, because the first part of it is forgotten ere the 
last part of it is heard. In presenting material, therefore, 
sentences should be short, definite, and clear. Enumeration 
of a number of conditions that must be held in mind and upon 
which the correct answer depends leads to confusion and 
serves rather to obstruct than to facilitate development of 
power to think. In a conversation on this topic a teacher of 
some years' experience recently said to me: "That's just one 
of the points where I used to fail. I would ask a question and 
then add something to it to make it clear, when in reality I 
was only making it the more confusing to the minds of the 
pupils." 

This is by no means a complete list of the mental differ- 
ences between the young child on the one hand and the adoles- 
cent or adult on the other, but possibly these cases will serve 
to illustrate the principle that a hygienic instruction is one 
which is fitted to the stage of mental as well as physical de- 
velopment of the child. 

Condition of Health. — Instruction in school should not 
proceed independently of the condition of the pupil's health. 
Most of the topics related to this principle belong properly 
in a discussion of school medical inspection and are discussed 
in detail elsewhere in this work. Little more than an enumer- 
ation of the most important ones is needed in this connection. 

Freedom from disease, a well-nourished condition, good 
posture, good digestion, ability to sleep well — all these are 
essentials for mental as well as physical development. There 



THE GENERAL HYGIENE OF INSTRUCTION 33 1 

should be no hindrances to respiration. The child with ob- 
structions such as adenoid growths in his nasal passages is 
less able to give sustained attention and profits much less 
from instruction than the one that breathes freely. Kaffe- 
mann is reported to have demonstrated experimentally that 
children with artificial nasal obstructions showed a decrease 
in abihty to retain memory material. But more than this, 
it is a well-known fact that the child with adenoids is hable 
to be inattentive and "dull," and that he benefits both phys- 
ically and mentally when they are successfully removed. 
Attention has elsewhere been called to the relation of physical 
defects to school progress. Tonsilar disturbances and en- 
larged glands should be carefully watched for and treated 
when necessary. 

While not attempting to state which w^re the causal 
factors, Quirsfeld reports that he found among German chil- 
dren that a condition of lack of nourishment, weak muscu- 
lature, enlarged glands, and weak mental powers were very 
liable to be found in the same pupils. 

Since so much of the child's knowledge must be received 
through ear and eye, it is extremely important that these 
organs be free from defects. Special classes, if need be, 
should be furnished for those children who hear poorly. 
Meumann says that such conditions as bad hearing may go 
so far as to cause moral injury. Care of the eyes is equally, 
if not more, important. All the things that may be said re- 
garding hygiene of vision apply here. 

Good teeth, properly cared for, are essential to the health 
and comfort of the child and also to good school work. 
Numerous school dental clinics in this and other countries are 
evidence that this fact is being recognized. Rose has re- 
ported that among German children physical development 
was greatly influenced by defective teeth, that poorer physical 
development was accompanied by poorer mental power, and 
that the poorer the teeth the worse on the average were the 
grades of the children. 



332 EDUCATIONAL HYGIENE 

Finally, children with nervous disorders and symptoms of 
neurotic condition need the most careful attention. They 
should be free from strain of all kinds, in order to guard 
against nervous and mental disturbances that may be both 
serious and permanent. 

Some precaution is needed, also, to prevent the spread of 
such things as bad motor habits, tics, and even in many cases 
certain defects of speech, which may easily become ^'psychic 
contagions." 

The above list of topics is perhaps not entirely new, but 
the thing to be emphasized here is that these things are im- 
portant for instruction, also for mental development. The 
maxim should always be: "Health first, then instruction." 

Optimum Conditions for Work. — ^Having fitted the de- 
mands of the school to the child's innate ability, stage of 
development, and condition of health, the next step should be 
to look to the conditions under which the work is to be done. 

Sufficient room for work, and an abundance of light and 
pure air, are essential. Undue distractions should be elimi- 
nated as far as possible. School-buildings should be located 
in quiet districts. 

Subjects requiring strenuous effort should be studied during 
the early forenoon, when, as experiments have shown, the 
maximum of ability for the day is reached. Habit studies 
and routine work may come in the late forenoon or in after- 
noon hours. Daily application to strenuous work at a time 
when energy is at its ebb may be expected to result in nerv- 
ousness, headaches, and a minimum of acquisition of real 
power. On the other hand, periods of the most strenuous 
work should not immediately follow each other. Ability is 
influenced by preceding work as well as by time of day. 
Strenuous tasks should be followed by a period of relaxation 
or lighter work before other equally strenuous tasks are begun. 

Seasonal variations have also been noticed. Apparently 
the tide of mental abihty runs low during the spring and 
early summer, when physical growth is greatest. School work 



THE GENERAL HYGIENE OF INSTRUCTION SS^ 

should be a little less strenuous at this time. On the basis of 
the same facts, the spring vacation finds a hygienic justifica- 
tion. 

Some attention must be paid to the social environment. 
The presence of the teacher, the presence of other pupils, the 
knowledge of their attitudes toward the work being done — 
all these are of significance for the healthful exercise of the 
pupil's mental powers. Too great variation of abihty in one 
class is bad. The best are not stimulated to work; the poorest 
are too much discouraged to do so. On the other hand, abihty 
should not be perfectly uniform. A slight inequahty stimu- 
lates the entire group to better efforts and greater develop- 
ment. Social environment is also a factor in the determina- 
tion of whether home work is good or bad. For example, 
Schmidt found that among the parents of cl^ldren who were 
doing home work some could be classed as ^'demanding," 
some as ^'hindering," and still others as "indifferent." Hy- 
gienists seem to be agreed that there should be no regular 
home work for any of the pupils of lower grades. There is 
less agreement with reference to home work by pupils of the 
upper grammar grades, but most admit that high-school 
pupils may do some home work without injury. 

These conditions need attention if the surroundings of the 
school-child are to be made conducive to efficiency of work 
and a healthful development. School work is sufficiently un- 
natural and difficult at best, and injuries sufficiently numerous. 
Every precaution is needed to keep the child body and child 
mind growing and reacting normally and to prevent the fur- 
ther multiplication of "school injuries." Conditions should 
therefore be as nearly the best as it is possible to obtain. 

Alternation of Work and Rest. — ^That the development of 
an organism is conditioned upon the rhythmical alternation of 
functioning and inactivity is a fundamental biological law. 
That this is true of physical development has been demon- 
strated by every athlete that ever went into training. Based 
upon this is the hygienic principle that periods of work should 



334 EDUCATIONAL HYGIENE 

alternate with periods of rest. The old maxim that "exercise 
strengthens'' suggests at once the classic example of the 
blacksmith's arm, but a similar influence from exercise is as 
real in case of mental as in case of physical development. On 
the other hand, we scarcely need be reminded that the black- 
smith does not use his arm without ceasing. Rest and time 
to rebuild tissue are essential. And if this is true for the 
hardened muscular cells of the blacksmith's biceps, how much 
more true is it for the delicate brain and nerve-cells upon 
which mental work depends! 

If such analogous reasoning does not suffice, then one needs 
only to observe the nervousness, the inattention, the inability 
to think, that are displayed by a group of pupils at the close 
of a long and fatiguing school session. 

Work is essential to development, but so also is rest; and 
both development and health are conditioned upon their 
proper balance. It is well for the child to work until he is 
tired, but he must have opportunity to rest afterward, not set 
to work immediately upon another fatiguing task. The meas- 
ure of this balance is the readiness with which the child re- 
covers. Prolonged work, whether physical or mental, is sure 
to result in nerve strain, and a condition of nerve strain is a 
condition of strength drain. When the strength thus drained 
is not recovered within a reasonable time, there is danger of 
injury. 

The applications of this principle are many. I mention 
a few of the more important. The position in which the work 
of the school is to be done should be natural. When the 
strain from unnatural positions becomes too great, the child 
slumps down in an attempt to ease himself — to get needed 
rest-— and bad posture with its attendant ills results. Strenu- 
ous physical exercise should not follow difficult mental work, 
especially where movements are difficult and require close 
attention. This does not rest; it only increases the fatigue. 
Conversely, a strenuous physical exercise should never be 
followed immediately by difficult mental work. Exercises in 



THE GENERAL HYGIENE OF INSTRUCTION 335 

singing, especially those in which attention to the reading of 
music is involved, should never be substituted for actual rest. 
They require attention and expenditure of energy and are 
more liable to produce than to relieve fatigue. Finally, by no 
means least in importance, frequent recesses should be given. 
Better work has been shown to result when recesses were fre- 
quent and short than when they were less frequent, even 
though longer. 

Mental Hygiene 

Mental hygiene as a science, the nativity of which does 
not date very far back in years, is founded largely upon con- 
tributions from psychology, normal and abnormal, psychiatry, 
physiology, and neurology. These sciences have in recent 
years contributed many significant facts regarding mental 
functioning and mental development and the conditions upon 
which they depend. It has been shown that much of the so- 
called abnormality, and much of the insanity even, is in great 
part the result of faulty mental habits developed early in life. 
The treatment for such conditions consists essentially in a re- 
education in proper habits of thinking. 

Now, as has been repeatedly pointed out by Doctor 
Burnham, it is certainly a fact of some significance that many 
of the patients now receiving their re-education in special 
institutions were only a few years ago pupils in the public 
schools. A properly applied mental hygiene there would have 
instituted correct mental habits in a high percentage of cases 
and thus acted, at least in many borderline cases, as a pre- 
ventive of much of the suffering, not to mention the expense 
and economic loss, to society. It is thus clear at once that the 
hygiene of instruction is in large part a mental hygiene, and 
this means that the school must pay proper attention to the 
cultivation of good mental habits. 

Of prime importance here are habits of attention, associa- 
tion of ideas, and emotional expression. All these are es- 
sential to instruction at every point. Each involves and is 



336 EDUCATIONAL HYGIENE 

conditioned by the others in almost every situation, so that it 
is almost impossible to discuss them separately. Let us there- 
fore turn attention for a few moments to the meaning and im- 
portance of each, taking up later the appUcations to school 
work and the conditions upon which they depend. 

Attention. — From the functional view-point, attention is 
that reaction by virtue of which elements in a situation be- 
come more or less clear in consciousness. In its simplest, 
most primitive form, the reaction is direct and immediate, in 
response to a stimulus. In its developed fonn it is selective 
in its nature; certain elements are either pushed into the 
background or "fringe" of consciousness or excluded entirely, 
while others are brought to the foreground and thus become 
more clear. 

But we must take care to interpret correctly. Conscious- 
ness is not static. Attention does not render its elements 
fixed. With a sort of panoramic sweep they change and flow, 
creating ever a new situation. In fact, the figure "stream of 
consciousness" has been very fittingly applied. There is 
therefore a constantly recurring readjustment, a shift of at- 
tention from moment to moment. 

Now the ability to adjust to these changes, the ability to 
attend in a proper manner, is at once vital to clear thinking 
and to mental development. The lack of this ability, on the 
other hand, means difficulties of thought, abnormalities of 
mental development, and, in extreme cases, entire loss of 
mental balance and a pathological condition. The whole 
matter is, of course, complex; but, even though such phe- 
nomena as emotional response and association of ideas are 
involved, it may yet be said that abihty to attend properly 
is largely a matter of habit. This is the point at which the 
topic of attention is linked with the hygiene of instruction. 
It becomes the business of the school to drill pupils, so far as 
is possible, in healthful habits of attention. 

The healthful form for developed attention is suggested by 
the simpler, more primitive form. As intimated before, this 



THE GENERAL HYGIENE OF INSTRUCTION 337 

is direct and simple, bringing one element to the foreground. 
The school, therefore, should drill its pupils to attend to a 
situation in such a way that the essentials are brought to the 
foreground, while unessentials, whether relating to past, 
present, or future, are either excluded entirely or else pushed 
into the background or fringe of consciousness. In ordinary 
terms, this means the ability to concentrate upon the essen- 
tials of a situation, shifting attention from moment to moment 
in a way to present them to consciousness from a new view- 
point. To the problem of how this is to be accomplished in 
the school we shall a little later return. 

Association. — Training in good habits of attention should 
be paralleled by training in habits of orderly association of 
ideas and the avoidance of interference. Briefly stated, in- 
terference means a struggle of ideas for possession of the fore- 
ground of consciousness. This problem has been dealt with 
in detail by Doctor Burnham, who would make the avoid- 
ance of interference the most general negative rule in mental 
hygiene. ''We find interference of association," he says, ''in 
an infinite number of forms, from the conflict of simultaneous 
stimuli in the nervous system and the relatively simple in- 
terference of incipient motor habits up to the confusion of 
thought in the individual who is worried or rattled or the 
patient who suffers from the insanity of doubt." 

All persons experience an occasional interference of as- 
sociation. For example, do you spell receive with an ei or 
is it ie? Was it number 368 or 836? Or, again, a name can- 
not be recalled because a similar name crowds to the fore- 
ground and usurps the focus of consciousness. 

Ordinarily these experiences last for but a moment, or at 
least for a few minutes, and are apparently harmless enough. 
Unfortunately, however, this is not aLways the case. Inves- 
tigations have shown that, especially in case of persons with 
unstable nervous systems, conflicts of ideas or of complex 
systems of ideas may under the influence of strong emotional 
toning finally result in serious pathological conditions such as 



338 EDUCATIONAL HYGIENE 

obsession, dissociation, disintegration of personality, and loss 
of sanity. 

I do not mean to assume that every case is to be taken as 
an indication of a pathological condition. I do wish, however, 
to lay stress upon the necessity of proper habits of association 
of ideas as an essential to mental health and the development 
of the power to think clearly; and I insist that it is imperative 
that the hygiene of instruction take account of these facts, 
namely: (i) In extreme cases interference of association may 
form the basis of bad habits of thought which lead later to 
pathological conditions and loss of sanity; (2) interference is 
ordinarily a common and normal occurrence but is often ab- 
normal, and forms an obstruction to the free flow of ideas and 
to logical thinking and a hindrance to proper mental de- 
velopment; (3) the most successful method for treatment of 
pathological cases — the method of re-education — points to 
education in proper habits of association in the early years as 
the best means for prevention of such cases; (4) it therefore 
devolves upon the school, which assumes the burden of edu- 
cating and moulding the child to so great an extent — ^largely 
by means of association of ideas — to see that instruction be 
such as to avoid as much as possible the abnormal interfer- 
ence of these associations and that proper habits be developed. 

Emotions. — ^Habits of emotional response make up a third 
element of significance for mental health. Indeed, it is im- 
possible absolutely to separate the child's emotional from his 
intellectual development — a fact, sad to say, that has not 
always been recognized by the schools. 

The influence of affective or emotional elements upon con- 
scious reaction has been clearly demonstrated in laboratory 
experiments during the last decade. Evidence of this is found 
in the *' attitudes" that are so often to be dealt with in the 
working out of psychological problems. One needs but to 
mention a few of them, such as attitudes of indifference, prej- 
udice, approval, etc., to show that they are normal matters of 
every-day experience. But they are not always necessarily so. 



THE GENERAL HYGIENE OF INSTRUCTION 339 

A persistent habit of assuming an attitude of disapproval may, 
for example, readily transform an individual into what is 
popularly termed a chronic grouch; certainly a habit that 
is not conducive to mental health. Similarly many other bad 
attitudes, such as jealousy, suspicion, distrust, etc., may be- 
come so ingrained as to become a hindrance to normal, health- 
ful mental reactions. But these are only mild cases. In ex- 
treme cases, when combined with other bad mental habits, 
such as interference, for example, affective and emotional 
toning becomes an important factor in the development of 
pathological conditions. Interference, emotionally toned, 
begets worry; worry aggravates interference; and so the evil 
spreads until the victim is hopelessly enmeshed in a tangle of 
conflicting ideas and compelHng emotions from which it is 
impossible for him to extricate himself. % 

It is a duty of the school to do all in its power to develop 
in the pupils those attitudes that are conducive to mental 
health. Possibly the whole secret for doing this has not yet 
been given to the world in full; but a large part of the secret 
is contained in the following expression : Freedom, Naturalness, 
Self-expression, Interest. 

Practical Applications. — Some practical suggestions as to 
how the principles of mental health may be applied in the 
schoolroom are in place here. 

(i) Make the instruction such as to enlist the permanent 
interest of the child. Faithful, energetic work on a problem 
of vital interest, even though it be not of long duration, will 
do much to develop good habits of attention and of associa- 
tion. 

(2) The injunction to guard against overfatigue is again 
in place here. The fatigued child is the inattentive child, 
or, perhaps better, the badly attentive child. It is in this 
condition, too, that associations go wrong and interference 
is liable to be initiated, and unhealthful attitudes toward 
work develop. 

(3) Make statements and questions commensurate with 



340 EDUCATIONAL HYGIENE 

the limited attention span of the child. Do not "scatter" 
the attention and initiate interference by means of much and 
confusing diction. 

(4) Problems and tasks should not be too complex. 

"One thing at a time, and that done well, 
Is a very good rule, as many can tell." 

In beginning penmanship, for example, it is too much to ex- 
pect the young child to attend to the form of the letters, 
spelling of the words, holding to the line, neatness, manner of 
holding the pen, and posture, all at one time. 

(5) Take account of the kind of work to be done and use 
a few moments to teach the pupil how to study it. For 
example, a leading question or two may make the difference 
between a history lesson carefully studied with interest and 
good attention, or a history lesson which is uninteresting and 
"memorized" imperfectly with many a shift of attention. 

(6) In making assignments, give a definite task commen- 
surate with the child's ability, require him to do it, then give 
some chance for relaxation. 

(7) See that each child in the class or in the school suc- 
ceeds at something. Not to do so is to bid for discourage- 
ment and unhealthful attitudes on the part of some pupils. 
Nothing is more true than the old maxim that " nothing suc- 
ceeds like success." 

(8) Select as teachers persons who are optimistic, joyous, 
tactful, enthusiastic, and sympathetic; and let teachers them- 
selves practise good mental hygiene in the realization that 
most irritable, pessimistic, exacting attitudes of mind can be 
changed. 

Summary 

To summarize very briefly, the problems of the hygiene 
of instruction are those which have to do with the health and 
the normal development of both body and mind. The sub- 



THE GENERAL HYGIENE OF INSTRUCTION 34I 

ject is therefore broad in its scope. As a result of the solu- 
tion, or partial solution, of the problems concerned, the fol- 
lowing general principles may be stated: The demands of in- 
struction should be fitted first of all to the child's innate 
ability, stage of development, and condition of health, after 
which he should be given as nearly as possible optimum con- 
ditions in which to work; work and rest should be properly 
alternated in order to avoid injury from overfatigue; finally, 
regard should be had for the laws of mental health, so far as 
they are known, care being taken to develop proper habits 
of attention, association of ideas, and emotional response. 



CHAPTER XIX 
THE HYGIENE OF SCHOOL SUBJECTS 

In this chapter the attempt is made to indicate some of 
the appKcations of the principles indicated in the preceding 
one to some of the most important subjects of the school 
curriculum. It is impossible to make a complete list, but the 
treatment of these most important subjects will, I hope, be 
of value. 

Reading. — ^The emphasis upon reading is so nearly uni- 
versal, both throughout the school years and throughout Hfe, 
the amount of time spent upon it is so great, and other sub- 
jects in the school depend so much upon it, that compliance 
with the demands of hygiene for as nearly optimum conditions 
as possible becomes imperative. Without attaching special 
significance to their order, let us turn attention to the most 
important of these demands. 

(i) First, hygiene demands that proper regard be had for 
the posture of the child. Suitable seats and desks, more 
complete descriptions of which are to be found in another 
chapter, are a necessity. They should be suited to the size 
of the pupil and so constructed as to make possible an easy, 
erect position, without strain; and they should support the 
book in a way to make reading possible without stooping 
and without bending forward the head or the body. Standing 
in line and holding heavy volumes in position for reading 
should not be required of pupils. Indeed, heavy volumes for 
regular use in any subject should be avoided, especially in 
case of the younger pupils. The carrying of such books is 
liable to be injurious. 

(2) In the second place, hygiene demands that oral read- 

342 



THE HYGIENE OE SCHOOL SUBJECTS 343 

ing should have proper regard for the organs of speech. Here 
are involved organs of respiration, vocalization, and articu- 
lation, and any rules having reference to their proper care, 
development, and training are applicable to the hygiene of 
reading. 

In proper amounts and under proper conditions oral read- 
ing is a healthful exercise. Good breathing exercises and the 
development of good breathing habits are of value. The 
use of pure tone should be cultivated, but it should not be a 
monotone. Reading with expression brings various muscles 
into play, thus preventing rapid fatigue of the vocal organs. 
Training in habits of articulation is also valuable, since both, 
in school and out a Httle articulation is better than much 
loud talking for making one's self heard, and it is much less 
injurious to the vocal organs. ^ 

Reading should never be so long nor so loud as to cause 
strain, hoarseness, or overfatigue of the vocal organs. Es- 
pecially in the early years, excessive strain should be avoided; 
also at the time of voice mutation, which usually occurs at 
about the pubertal period. So also in case of colds or sore 
throat, after certain diseases that affect the throat, and where 
there are nasal obstructions or tonsilar disturbances, over- 
strain should be guarded against. Bad nasal and tonsilar 
conditions should receive medical attention immediately. 

Speech defects constitute a special problem. Their causes 
are numerous, many of them lying outside the school, and in 
so far as treatment is concerned the cases belong in the hands 
of specialists. Within the school, however, oral work may be 
of value by drilling in habits of slow, deep breathing, rhyth- 
mical speaking and proper articulation of words, thus pre- 
venting or correcting bad habits which are liable to be con- 
tributing factors to defects of speech. 

(3) Hygiene demands that care be taken to prevent 
school-books from becoming media for the spread of disease. 
Books pass from hand to hand and are Hable to be thumbed 
by a number of individuals. Turning of pages with the tip 



344 EDUCATIONAL HYGIENE 

of the finger moistened in the mouth should never be tolerated. 
Special precautions are necessary in case of supplementary 
readers that are handed from class to class, also library books 
that circulate from home to home. The same applies to 
pencils and other objects, as taken up in the chapter on school 
sanitation. 

(4) A fourth demand has reference to the organs of vision. 
All rules regarding the care of the eyes apply here. Some of 
these need special emphasis. Light should be abundant, but 
should not fall on books and desks in a way to cause a glare. 
Rules for posture are important again in this connection. The 
distance of the book from the eyes should not be such as to 
cause strain of the visual organs in reading — never less than 
twelve inches, according to a special committee report before 
the American School Hygiene Association, 191 1. 

Near work should alternate with that giving opportunity 
for distance-vision, thus relieving the strain caused by ac- 
commodation of the eye for close vision. In the report of 
the British Association for the Advancement of Science, 191 2, 
the committee appointed to inquire into the influence of school- 
books upon eyesight writes as follows (p. 298) : 

Children who do too much close eye work suffer in various ways: 
some simply from fatigue, showing itself by inattention, mental 
weariness, temporary dimness of sight, or aching of the eyes and head; 
some from congestion of the eyes, as shown by redness, watering, and 
frequent blinking. A certain number, in circumstances which predis- 
pose them to the disorder, develop strabismus, or squint. Some others 
— and these cases are perhaps the most important of all — develop pro- 
gressive myopia. 

A special committee of the American School Hygiene As- 
sociation fixes the maximum time for the uninterrupted use 
of the eyes for near work at fifteen minutes for the first school 
year, increasing to one hour in the later adolescent years. 

Again, the undeveloped condition of the eye in the early 
years, the frequent lack of ability to fuse together the images 



THE HYGIENE OF SCHOOL SUBJECTS 345 

from the two eyes, the inability to hold the book at proper 
distance from the eyes because of the shortness of the arms, 
these and other facts indicate that instruction in reading 
should not begin too early. The British committee recom- 
mended that extended reading from books be postponed until 
the age of seven at least. Oral work, pictures, blackboard 
work, and wall charts are recommended for use up to this age. 
The "make up" of school texts is important. Author- 
ities are practically agreed as to the fitness of the following 
requirements: 

Paper should be white, without gloss, opaque, and sufficiently 
hard so that type does not press through. 

Illustrations should be plain and without fine detail, especially 
in the lower grades. 

Ink should be good black and evenly distribu^d over the page. 

Maximum length of lines should be 90 mm. (The British com- 
mittee gives 100 to 93 mm. — 3^ to 4 inches.) 

For beginners, lines should not end in the middle of a word. 

Series of short lines by the side of illustrations should not be used. 

Margins should be sufficiently wide so that the eye does not swing 
off the paper, and those next the fold of the book should be wide 
enough to prevent printing from being hidden by the curvature of 
the paper. 

Type should be clean-cut, making lettering with clear and well- 
defined lines, especially in the upper half, and whites and blacks 
should be evenly balanced. Italics should be used very little. 

The committee of the American School Hygiene Association 
gives the following as minimum standards for type, spacing, 
and leading for the earlier school grades: 

A. First grade — 

(i) The height of the small letters should be at least 2.6 mm., 
with the other dimensions in proportion. 

(ii) The width of the vertical stroke should be from .4 to .5 mm. 

(iii) The space within the letters should be from .8 to .9 mm. 

(iv) The space between the letters should be about i mm. 

(v) The space between the words should be about 3 mm. 

(vi) The leading should be from 4 to 4.5 mm. 



346 EDUCATIONAL HYGIENE 

B. For the second and third years the standard may be reduced 

slightly, but the letters should not be less than 2 mm. in 
height and the leading should be 4 mm. 

C. For the fourth year height and leading should not be less than 

1.6 mm. and 3 mm. respectively. It would be better to re- 
tain the standard of the fourth year through the sixth year. 

The British committee is somewhat less liberal in its recom- 
mendations for size of t3^e, but more liberal as regards lead- 
ing, or interlinear space. 

(5) But, after all, standards and objective material are 
but means to an end. These are furnished and should be 
properly used in order that the cliild may learn to read. And 
reading is to interpret symbols presented. It is something 
psychological, a series of mental processes. A fifth and per- 
haps most important demand of hygiene is. therefore that 
reading should not be detrimental to the mental health of 
the child. 

Now, the earlier years are the time par excellence for play, 
for telling of stories, and for relating personal experiences, all 
of which begin the development of and furnish the basis for 
habits of attention, ability to concentrate upon essentials 
while ignoring unessentials, practise in memorizing things of 
interest, and in giving logical expression to ideas — all essen- 
tials to mental health, as outlined in the preceding chapter. 
On the other hand, as Doctor Fitz has pointed out, reading 
too early is liable to crowd out these activities and leave the 
child grinding over the memorization of symbols that are 
arbitrary and uninteresting. He develops the habit of look- 
ing too much at the symbols, not through them, to the thought 
— a habit which may retard him in his future reading when 
the getting of the thought is essential. 

The statement may therefore be repeated here with em- 
phasis that regular work in reading should not be required 
of the child in the early years. Many of the best educators 
maintain that reading should be postponed until the age of 
eight. To quote Doctor Fitz: 



THE HYGIENE OF SCHOOL SUBJECTS 347 

Experience has shown, over and over again, that the child who 
begins to read at eight years is in no wise handicapped in his later 
educational progress. He has the inestimable value of the advantage 
of intense interest, rounded by his sense of power in unlocking the 
secrets of books and papers after the fashions of his elders. Increased 
maturity makes the slow, irksome task pleasurable and easy. 

The slower association time of the child makes it wrong 
to demand too rapid reading, especially when the material is 
new and unfamiliar. Ideas that should be associated with 
the symbols come slowly and attempts to force them are 
liable to cause either wrong associations or interference. 

To summarize briefly, then, the reading of books in the 
school should not be required under conditions that are lia- 
ble to cause bad posture or to result in injury to the organs 
of speech or of vision; books themselves should not be media 
for the spread of disease; and finally, instruction in reading 
should be given neither at such an early age nor by such meth- 
ods that it may become a hindrance to mental development 
and the formation of good mental habits. 

Arithmetic. — As one of the "three R's'^ arithmetic has 
always had a place of great importance in the schools. Its 
general hygienic requirements are much the same as those for 
reading. 

The great amount of desk work that must be done neces- 
sitates attention to the proper adjustment of seats and desks 
with a view to securing good posture. Height of blackboards 
from the floor also should correspond to the size of the pupils. 

Care of the eyes makes it necessary that proper conditions 
of lighting be furnished and that the ''make up" of texts 
conforms to all the requirements given in the preceding sec- 
tion for reading-books in general. Special emphasis should be 
placed upon the requirement that diagrams and illustrative 
drawings be clear and that all figures, especially fractions, 
be in large, good type. The British committee would have 
all mathematical s3mibols in sHghtly larger type than other 
material. Blackboards should be of proper color and of good 



348 EDUCATIONAL HYGIENE 

material, and lettering to be read by pupils in the room should 
be sufficiently large and clear to be read without difficulty or 
eye-strain. 

With a view to taking precautions against spread of dis- 
ease the use of slates may well be prohibited entirely, also 
the loaning of pencils among pupils. Crayons should be 
selected with care and pupils should be taught how to erase 
the blackboards properly in order to avoid as far as possible 
filling the air with dust. 

From the view-point of the child's mental development 
a number of things are significant. First, the age at which 
formal arithmetical study begins should not be too early. The 
power of abstract reasoning develops late, as was stated in 
the preceding chapter. Attempts to force its development 
at too early an age are liable to result in retardation or arrest. 
Doctor Triplett has shown that too much stress on arithmetic 
in the early years often results in bad mental habits, such 
as the incessant counting habit known as arithmomania or 
the fixation of incongruous "number forms" which are liable 
to persist as obstructions to logical arithmetical thinking. A 
number of the best authorities maintain that arithmetic 
should be postponed until the age of eight or ten years. 
Finally, bad attitudes may be the result of too early stress 
upon the subject. Says Doctor Fitz: 

. . . Much of the aversion to arithmetical problems found later 
is undoubtedly due to the disheartening drill of this primary work. 
Here again the child who begins arithmetic at eight or ten years of 
age finds himself able to take it up quickly and has the liking for it 
that easy mastery always gives. 

Again, collected statistics show that from one-sixth to 
one-fourth of the time of the school is devoted to the study 
of arithmetic — an amount entirely out of proportion to the 
value of the subject for mental development. Courses are 
as a rule made to include too much. Topics are taught 
because found in the texts and they are in the texts because 



THE HYGIENE OF SCHOOL SUBJECTS 349 

they have always been in other texts before. The result of 
all this is, in many cases, overpressure, nervousness, and 
injury to mental health and development. 

A number of mental processes are involved in arithmetical 
work. Much would be gained for the hygiene of the subject 
if this were recognized in a practical way. For example, 
where mere association of ideas is involved, account of the 
fact should be taken and drill in formation of the proper as- 
sociations should always precede drill for speed. Or, again, 
much of the subject is merely application of a new form 
of expression, a new language, to a form of reasoning with 
which the pupil is already familiar. Thus, both ratios and 
common fractions are neither more nor less than unexe- 
cuted divisions, decimals are specialized fractions written in 
new form, and percentage is perfectly simpje when treated 
as a subdivision of decimals with symbol series of its own. 
Doctor McDougle has emphasized the proper sequence and 
proper relationship of these topics for the pedagogy of the 
subject. The hygienic value from such a procedure would 
perhaps be even greater, eliminating innumerable difi&culties 
of thought and causes of interference and unhealthful atti- 
tudes. Doctor Burnham has emphasized the importance of 
ehminating the type of complex problem which is in its es- 
sentials a logical trick and has little to do with reasoning 
about numerical relations.^ 

Geography. — ^The demands of hygiene upon geography, 
in so far as its influence upon physical health is concerned, 
have particular reference to posture and to vision. 

In case of the former the conditions within the school- 
room and the hygienic demands are practically the same as 
in case of reading, except in the special work of the drawing 
of maps. There the rules found under the discussion of 
drawing will apply. It may be added, however, that map- 
drawing should not constitute a large part of the course. 

1 See also Jessup's studies of eliminations in arithmetic in the 1915 year-book 
of the National Society for the Study of Education and in the 191 4 and 191 5 
proceedings of the National Education Association. 



350 EDUCATIONAL HYGIENE 

As regards the care of the eyes, also, the general rules in- 
dicated in the discussion of reading apply. In addition to 
these, however, some special precautions are made necessary 
by the extensive use of maps. First, the matter of the con- 
struction of maps is of importance. They should not be 
made to contain too much of detail, and should only contain 
such lettering as is necessary to make their meaning clear. 
The suggestion of Burger stein that all the important names 
in wall maps be large enough to be read by the entire class 
is good. The special committee of the British Association 
for the Advancement of Science recommends that no school- 
atlas should use type smaller than eight-point, with a mini- 
mum height of short letters of 1.2 mm., and that for chil- 
dren below the age of nine years nothing below ten-point, 
with a minimum height of short letters of 1.6 mm. (tV inch) 
should be used. Separate maps should be used to represent 
physical and political characteristics. As regards the use of 
maps a suggestion of the British committee may be quoted: 

Location by reference lines should be taught from the beginning, 
and children should not be allowed to hunt for a name in an undi- 
rected fashion, as they may thus have to read fifty names in finding 
the one sought. 

In a more general way, geography may be said to be a 
subject of health opportunity. Outdoor excursions and trips 
to places of interest may do much for the general health of 
the pupils and are to be encouraged. 

From the view-point of mental development, also, geog- 
raphy may be said to be a study of opportunity. Pedagog- 
ically, the aim is to teach of the earth as the home of man. 
If this is done properly, with the use of concrete material 
wherever possible and with many properly managed outdoor 
excursions, the child comes into possession of a wealth of 
concrete ideas which, as investigations have shown, are so 
often lacking in school-children but which are essential to 
proper mental development. 



THE HYGIENE OF SCHOOL SUBJECTS 351 

On the other hand, investigations have shown that unless 
special care is taken in the use of such material as charts, 
maps, and globes there may develop peculiarities and bad 
mental habits which may persist as obstructions to clear 
thinking. "When I get big I am going to move into that 
State, 'cause there the grass and flowers and trees — everything 
is all pink,'^ confided a small boy to his teacher as he pointed 
to a bright spot on the map before him. This is a typical 
case. Doctor Triplett reports that no individuals asserted 
that map-drawing had produced inabihty to image places 
on the earth, a map being called up instead. One student 
reported as follows on the result of four years of study of 
geography, supplemented by much practise in locating places 
upon a large colored map: 

% 
... In consequence I still think of all States as little patches of 
green, red, or yellow, as the case may be. That result I do not regret 
so sorely, for it is a common thing. But, worse than all, the map was 
hung during all those years upon the south wall of the schoolroom. 
This reversed all the directions and I still think of Washington State, 
for instance, as being southeast of here, Florida as being northwest, 
etc. It would be almost impossible for any one who had not had a 
similar experience to imagine how very strong this association is. 

Speaking of such cases as ''arrests" and commenting upon 
their causes and the form they take, Doctor Triplett writes: 

. . . The prevalent idea that one must be able to locate every 
place, whether of consequence or not, on the ground that it may be 
needed in one's reasoning appears responsible for the close memory 
grind of insignificant details. Overemphasis on the study of map- 
drawing is without doubt the strongest element in the production of 
the effects characteristic of these arrests. A large majority being 
of the visual type, extreme concentration on a symbol during the most 
plastic period of life habituates to the use of the fixed mental images 
of maps, globes, etc. 

Maps should be used to aid in the instruction of pupils 
concerning the things they represent, not merely as subject- 



352 EDUCATIONAL HYGIENE 

matter, to be learned as they stand; map questions should be 
used only in reviewing and summarizing, never in introducing 
pupils to the study of a country, except in the most general 
way; and care should be taken always to see that the ideation 
of the pupil reaches beyond the map to the actual things it 
represents. 

Writing. — ^The most important phases of the hygiene of 
writing, in so far as physical health is concerned, have refer- 
ence to its influence upon posture, vision, and the develop- 
ment of muscular control. 

The necessity of good seats and desks of the proper size 
for the purpose of securing good posture is self-evident. 
As regards other requirements, possibly a brief summary of 
those enumerated by Doctor Burgerstein would be of most 
value in this connection. . They are as follows: 

(i) Body erect, without bending to the side and without a twist 
in the horizontal axis, and with breast not touching the edge of the 
desk. 

(2) Head very slightly inclined, eyes being as far from the paper 
as height of the body in good position will allow — never less than 
thirty centimetres. 

(3) Feet neither crossed nor drawn under the seat, but with soles 
resting on foot-rest or on the floor. 

(4) Arms held so that elbows are about a handbreadth from the 
body, forearms with about two-thirds their length on the table and 
almost at right angles to each other. 

(5) Hand with palm turned slightly to the left and resting upon 
the nail of the bent little finger, upon which the other fingers are sup- 
ported, one above the other. 

(6) Penholder, which should not be too short, should not be 
grasped too near the pen; held with upper portion pointing toward 
the elbow. 

(7) Writing periods to alternate with rest periods, gymnastic 
exercise, or oral instruction whenever the majority of the class begin 
to show signs of fatigue. 

(8) Copy-book so placed that it is in front of the median line of 
the body; lines parallel to the edge of the desk in vertical, but slanting 
upward to the right for slant script. 



THE HYGIENE OF SCHOOL SUBJECTS 353 

Proper attention to vision makes necessary the followino- 
requirements: 

(i) Well-recognized rules for lighting should be observed. 

(2) The use of slates should be prohibited. 

(3) Writing-paper should have a good surface, being neither rough 
nor glaring, and should not be so transparent as to allow script to be 
visible through it. 

(4) Ink should be a good black. 

(5) Guide lines on the paper should be of a good black, never 
light blue, as is often the case, and should not be complex. 

(6) Script should not be too small — small letters not less than 
three to five millimetres in height, according to Burgerstein. 

Some care should be taken for the neuromuscular develop- 
ment. Here may be mentioned the following: 

% 
(i) Strenuous drill in writing should not begin too early, as it 
requires too much of the accessory muscles. If reading should be post- 
poned until eight years, writing should be postponed until even later. 

(2) Script should be plain, without flourish, and should not be too 
small. 

(3) Pencils and penholders should be long and sufiiciently thick 
to be grasped with ease. 

(4) Copy-book lines should not be too long. In fact, books should 
not be used, a few sheets of paper of proper size being better. 

(5) The necessity for frequent periods of rest needs re-emphasiz- 
ing here. Prolonged strain due to too much writing may result in 
what is known as "writer's cramp." 

(6) When first beginning to learn to write, children should be al- 
lowed to use coarser material, such as blackboard and chalk, thus 
avoiding the fatiguing finer adjustments of hand to pencil, etc. 

Lack of space prohibits going into the controversy of 
vertical versus slant script. On the whole, it may be said 
that investigations seem to have indicated that, from the 
view-point of influence upon both vision and posture, the ad- 
vantage is with the former, but the present semi-slant systems 
may easily be used without sacrifice of posture if teachers 
use "never-failing watch and care." 

So far as mental development and health are concerned, the 



354 EDUCATIONAL HYGIENE 

problems of learning to write are those of association of the 
idea with the proper writing movement to produce the symbol 
and of the formation of habits. It should be emphasized 
here that learning correct forms should precede drills for 
speed, and that right habits should be mechanized as rapidly 
as possible, thus reducing the probability of interference of 
association.^ 

Drawing. — Properly employed, drawing may be a very 
healthful exercise. Like writing, however, a number of pre- 
cautions are necessary regarding it. 

General precautions are those against injury from poison- 
ous colored crayons, the use of sharp thumb-tacks, or any 
other material that might be injurious. Aside from these, the 
hygienic requirements are very similar to those of the hygiene 
of writing. 

Hygienic chairs, tables, and other furnishings are necessary 
to good posture. Other special requirements are given in the 
theses prepared by a committee of the Berlin Lehrverein, the 
main points of which are here enumerated: 

(i) Upper part of the body free and without strain, head inclined 
slightly forward, shoulders equal height, feet separate with soles on 
the floor. 

(2) Drawing surface directly before the middle line of the body. 

(3) Left forearm pushed forward on the table so that the lower 
part of the upper arm lies just over the surface yet so that the body 
may not be supported by it. Left hand holds drawing surface lightly. 

(4) Right forearm neither pressed close to the body nor used as a 
prop, but placed to make possible good free movement. 

(5) Right hand lightly supported on the point of the little finger. 
Wrist not touching surface of paper. Hand should not obscure the 
line that is being drawn. 

Proper care of eyes makes necessary these requirements: 

(i) Good conditions of lighting. 

(2) Use of white or yellow paper with good surface. 

* See Freeman, " The Teaching of Handwriting." 



THE HYGIENE OF SCHOOL SUBJECTS 355 

(3) Prohibition of drawing — especially such as map-drawing — 
for home work. 

(4) Refraining from use of fine lines and fine shadings. 

(s) Tests of vision, including color tests, before beginning tech- 
nical drawing. 

(6) Frequent changes from near to far vision, such as is required 
in drawing from models. 

Regard for the child's motor development makes it de- 
sirable that overstrain from too long periods, from use of 
too short or too slender pencils, drawing of too fine Knes, 
etc., be avoided. In all the early years drawing should be 
free-hand, and the materials should not be too fine. Tech- 
nical instruction should be postponed until near the pubertal 
period. 

So far as its relation to mental hygiene is conoerned, drawing 
is of great value as a means of expression, and normal expres- 
sion is a condition of development. The spontaneous drawing 
in the early years should therefore be encouraged. Artistic 
expression and appreciation is a later development and should 
not be insisted upon in the prepubertal period. 

Spelling. — Outside the school one is rarely called upon 
to spell words except when expressing his thoughts in writing, 
and, especially, in letter-writing. The chief aim in teaching, 
therefore, should be the association of the proper letter sym- 
bols with each other and of these with the proper writing 
movements. 

From either view-point, pedagogical or hygienic, it is es- 
sential that these associations be direct and that the habitu- 
ation of the writing movements be carried to such a degree 
that they will come as Kttle as possible into consciousness 
to obstruct the free flow of ideas. In brief, learning to spell 
should not become the cause of interference of association. 

For securing the results aimed at, several general prin- 
ciples may be laid down: 

(i) Wherever possible, make spelling secondary to some other 
activity. For example, in the early grades especially spelling should 



356 EDUCATIONAL HYGIENE 

be taught incidentally, along with other subjects. The act of spelling 
is thus not made an end in itself, and the danger of too much " symbol 
consciousness" is reduced. Special drill classes may well be post- 
poned until about the fourth school year. 

(2) Differences in type of mental imagery make it necessary that 
several methods be used, appealing to visual, auditory, hand-motor and 
speech-motor imagery, etc. 

(3) Investigations of the most economical employment of time 
seem to indicate that about fifteen minutes per day in the upper 
grades is all that may profitably be spent in column drill. 

(4) Avoid showing the child incorrect forms. Correct errors by 
showing the right spelling. Never strengthen the imagery of the wrong 
form by making it prominent. 

(5) Teach homonyms separately, thus avoiding the dangers of in- 
terference of association. 

(6) Finally, make the habits of writing whole words with one 
impulse of the will mechanical as rapidly as possible. Methods for 
doing this are: copying, writing from dictation, rapid writing of 
familiar material, such as poems, etc. With attention fixed upon the 
thought or the words, the matter of spelling is left more and more to 
the hand.^ 



Other Subjects. — ^Limits of space make it impossible to 
extend the list of special treatments further. Possibly the 
treatments here given will be sufficient to illustrate rather 
fully the application of the principles which were pointed out 
in the preceding chapter. Some of the other subjects that 
should be rightly included are: 

(i) Music, the essential hygienic considerations in which 
are attention to vision, to care of the vocal organs, especially 
at time of voice mutation, and to the development of neuro- 
muscular powers where the use of instruments is involved; 

(2) Language, in which the most important problems are 
those of association of ideas and formation of habits; 

(3) The more scientific subjects, which properly should be 
begun rather late, but which require special attention to the 
requirements of mental hygiene. 

In any specific case the problem will be the application 

.* See investigations by Ayres, Buckingham, Ballou, O'Shea, and others. 



THE HYGIENE OF SCHOOL SUBJECTS 357 

of the general hygienic principles laid down in Chapter XXX. 
These will never be found to conflict with sound psycholog- 
ical and pedagogical principles. Freedom of expression, cor- 
rect habits of attention, orderly association, a Hvely interest 
in the work at hand, all are vital to both health and growth. 
They constitute the magic which the pedagogist must use in 
order not merely to preserve from injury, but to transform 
the immature individuals daily thronging our schools into the 
master minds who will solve the problems of the future. 



IV. THE TEACHING OF HYGIENE 

CHAPTER XX 

THE TEACHING OF HYGIENE IN ELEMENTARY 

SCHOOLS 

I. The Importance of Hygiene in the Elementary School 
Curriculum. — ^The watchword of the present day is effi- 
ciency. The idea that our future welfare and prosperity de- 
pend on the conservation of our resources is fast gaining 
ground in America. The modern scientific conception of 
efficiency, which was born amid the needs of industry, is now 
being successfully applied to almost every field of human 
endeavor. Quite recently, however, we have begun to realize, 
as never before, that efficiency must begin with the health of 
the individual and not with knowledge and action. Ill health 
is now being looked upon as a great economic waste, and means 
are being taken to prevent it. Numerous insurance companies, 
for example, have appointed physicians and nurses whose 
business it is to keep the policy-holders well. Many indus- 
trial concerns, moved more by the idea of efficiency and 
economy rather than by a feeling of sympathy, have found 
it worth while to provide free medical attendance as well 
as high-class sanitary measures for their employees. As 
psychology and hygiene become more and more scientific it 
becomes clear that knowledge, skill, morality, the satisfying 
of all the worthy satisfactions of life, depend largely on health. 
In the light of such a growing conviction it is obvious that 
the three R's must recede to the background in their order of 

358 



HYGIENE IN ELEMENTARY SCHOOLS 359 

importance. It is immeasurably more valuable to be healthy 
•than to know how to diagram English sentences, bound 
Africa, or write a promissory note. The healthy boy or girl 
working under hygienic conditions is able also to do more 
school work and do it better. Hygiene must then be regarded 
as the most important subject of the curriculum. President 
G. Stanley Hall has well said: ''What doth it profit a child if 
he gain the whole world of knowledge and lose his own 
health?" We might well ask now: ''What is the present 
status of this important subject in the elementary schools?" 

II. The Failure of Health Instruction in the Grades. — 
That the health instruction in the public schools has im- 
proved within the last few years is not to be doubted; but its 
effectiveness is still to be questioned. Doctor McMurry, a 
member of the Hanus Commission which investigated the 
schools of New York City, found that the health instruction 
was wooden and far from practical. Rapeer, who made a 
careful investigation of the educational hygiene in twenty- 
five leading cities, says of the teaching of hygiene: '^And yet 
the subject is a tail-end subject, little emphasized, and fur- 
nished with poor text-books for the most part, and very fre- 
quently with poor teachers in the grades and high school. 
Colleges do not usually give credit for nor demand a knowledge 
of this vitally essential subject of health and how to get and 
maintain it, much to their disparagement, and consequently 
we find many schools almost entirely neglecting it." These 
two investigations reveal conditions that most educators 
would probably agree are typical of the whole country. 

The writer wishes to propose the following reasons for the 
failure in the teaching of hygiene in the grades below the high 
school: 

(i) The teachers as a class are not well prepared to teach 
hygiene. The training received in the normal schools has too 
often emphasized anatomy and physiology rather than hy- 
giene, and little or no time has been devoted to it in the 
regular normal-school course. As a result the teachers are 



360 EDUCATIONAL HYGIENE 

deficient in the right kind of knowledge. They have not yet 
learned to appreciate either the importance or the character 
of efficient health instruction. 

(2) The psychology and pedagogy of hygiene have not 
as yet been worked out, because hygiene is really one of the 
newest subjects in the curriculum. The disadvantage con- 
nected with the teaching of hygiene rather than arithmetic is 
obvious when one considers the splendid devices involving 
play and construction and the standardized subject-matter 
now in use in the teaching of arithmetic and the dearth of 
these devices and standards in the teaching of hygiene. 

(3) Many of the text-books still in use devote altogether 
too large a proportion of space to anatomy and physiology. 
Much of the material in these books is too difficult for chil- 
dren, and in some cases the way in which it is presented leads 
to prejudice against any further study of the subject. The 
writer has known of cases where the children referred to 
lessons in hygiene as "nasty." Such an attitude can scarcely 
be expected to inspire a love of health or result in hygienic 
practises. Fortunately, however, there are a number of good 
books on hygiene that have recently appeared that could be 
put into the hands of children with profit. 

(4) The hygiene that has been taught has been too gen- 
eral and abstract and has aimed at knowledge rather than 
health ideals and practise. For example, teachers often 
spend much time on the anatomy and physiology of the di- 
gestive system to the neglect of such vital topics as food 
values, the hygiene of eating, how to preserve food, how to 
keep it from becoming contaminated, the right kind of break- 
fasts for children, a good kind of lunch to bring to school, etc. 

(5) The instruction in hygiene is not well organized or 
standardized through the grades, hence repetition and tedium 
both for teachers and for pupils are common. There is also 
a common neglect of essentials. 

(6) The aims in teaching hygiene have not been clearly 
formulated. Few principals of the elementary schools have 



HYGIENE IN ELEMENTARY SCHOOLS 361 

clearly in mind what results they ought to get by the time 
the children get through the eighth or ninth grade, conse- 
quently there has been little systematic planning for results. 

(7) The teachers frequently do not like to teach hygiene. 
It is only natural to expect that such vagueness as to aims, 
values, and methods tends naturally to dull the teacher's zeal, 
spontaneity, and efhciency. She realizes her failures in teach- 
ing hygiene, has a hearty dislike for it, and slights the subject 
whenever possible. In short, the psychology and pedagogy 
of hygiene are still crude and unsystematic. 

This chapter is written with the idea of helping hygiene 
to find itself by suggesting some principles for guidance. 
The brevity and scope of the chapter make some of these 
assertions sound dogmatic. At best they can be regarded 
only as tentative. The old-fashioned instruction has been a 
failure. We must have a programme for further experi- 
mentation and advance. 

III. Fundamental Facts and Principles Involved in the 
Teaching of Hygiene. — ^It is the belief of the writer that 
methods of teaching hygiene should take into consideration 
the following facts and principles: 

(i) The fundamental aim in teaching hygiene should he the 
inculcating of the ideals and habits necessary for health rather 
than mere knowledge. It is better to have the habit of clean- 
ing one's teeth than to have all the information on the teeth 
that is available. To make the instruction in hygiene really 
effective the teacher should have a good knowledge of the 
psychology of habit formation, and how to apply it. When- 
ever possible, the instruction should be correlated with action. 
If, for example, the teacher wishes the children to clean their 
shoes before entering the schoolroom, she should see that a 
place is provided for that purpose, and she must then insist 
that the shoes be cleaned until the habit has been gained. 
If she wishes the children to hang their wraps on individual 
hooks, she must first see that there is a hook for each in- 
dividual child and that he knows where it is. She must then 



362 EDUCATIONAL HYGIENE 

see that he hangs up his wraps regularly until the process has 
become "second nature" to him. While it is true that prac- 
tise is more important than knowledge, yet the function of 
proper knowledge in promoting action should never be over- 
looked. Whatever may be said in disparagement of knowl- 
edge, it is nevertheless plain that it helps rather than retards 
the right kind of practise. 

(2) The child has Httle or no appreciation for health as a 
motive for future action. In the stirring draniatic world in 
which he lives there is almost no inclination to consider the 
remote consequences of his behavior on health. To say to 
the small boy, ''Now, Johnny, if you do not get plenty of 
fresh air you will not be strong," has little or no effect on 
Johnny. He is concerned with his immediate world and not 
with the problems that he is Hkely to have six months or ten 
years hence. Minor illnesses, which might be expected to 
serve as motives for action, are soon forgotten, and it is 
doubtful whether the more serious ones offer anything more 
than specific motives. The boy who is dangerously ill because 
of the eating of green apples may be forever cured of such 
action, but such an experience would not deter him, probably, 
from overeating generally. The child who catches cold as a 
result of neglecting to remove his wet clothing may of his 
own accord promptly change his wet clothing in a similar 
situation, but such an experience would not insure his taking 
plenty of exercise in the open air. 

(3) Health being inadequate as a motive, one of the 
teacher's great problems is to discover motives that will be 
effective. What is going to happen in some far-distant time 
does not interest the child in the least. The younger the child, 
the truer this is. All the instruction must centre around the 
child's needs and interests. The child is interested in the 
approval of the teacher, in activity, play, competition, and 
imitation.^ To such instinctive sources the teacher must 
turn for the forces which will assimilate her instruction and 

^ See Thorndike's " Original Nature of Man." 



HYGIENE IN ELEMENTARY SCHOOLS 7,67, 

make for action. To illustrate, a child may have no desire 
to keep his desk neat and clean, but if there is competition 
among the pupils of a school he is likely to develop a new 
interest in the appearance of his desk. Little children are 
naturally interested in playing at keeping house, having 
teas, etc. Teachers in the kindergartens and lower grades 
may easily divert these impulses into habits of school house- 
keeping and personal hygiene, such as dusting, setting the 
table, preparing lunches, use of napkin, proper chewing of 
the food, cleaning the teeth, and keeping the room free from 
flies. 

(4) Activity, mental and physical, is one of the essentials 
for health. The first law of the child's nature is action. Every 
stimulus around him moves him to act. There is little use 
in telling children about the great need o^ exercise. The 
problem is to give the children plenty of opportimity to 
exercise so that this tendency may not atrophy. It needs also 
to be directed along the right channels. If the teacher gives 
the child opportunity and stimulus to express his playful ac- 
tivities in the schoolroom and the playground, she will have 
accomplished more than would have been possible through 
any amount of formal instruction. A permanent interest in 
physical activity should be one of the goals of health instruc- 
tion. It is doubtful whether the work in physical culture in 
the elementary school has contributed much, if anything, to 
such an interest. 

(5) The structure of the body — something which the 
child cannot see and a knowledge of which is not necessary 
for the solution of his immediate problems — is not very in- 
teresting. Before the child leaves the grades he ought, of 
course, to have some kind of common sense and scientific 
knowledge of how his body is made and how it works, but such 
knowledge should generally be free of technical terms, and 
should in every case be presented to satisfy his curiosity or 
to support his knowledge and practise of hygiene. The 
GuHck ''Hygiene Series" (Ginn & Co.), for example, presents 



364 EDUCATIONAL HYGIENE 

in an interesting manner all the anatomy, physiology, and 
hygiene that the child needs to know.^ 

(6) There is grave danger in isolating the instruction in 
hygiene so that the child is led to think of hygiene as coming 
at a certain time of the day but having no further relation 
to his life activities. The teacher should seize opportunities 
in other lessons to give information in hygiene, and whenever 
there is occasion in the play or work of the pupils. Es- 
pecially desirable is individual instruction when it is needed. 
The teacher who advises a pupil who is anemic to walk to 
school rather than to ride in a closed car, and who afterward 
follows this up to see that it is done, has no doubt accom- 
plished more for the good of the child than would have been 
possible through any given class instruction for a year. In 
caring for children who have wet feet, in supervising the 
warming and eating of lunches at noon, in advising children 
who have colds of the best methods of treatment, the teacher 
may work most effectively. 

(7) In matters pertaining to hygiene, children should be 
taught and be led to act socially for the good of the group. 
To obey the laws of health is desirable not merely for one's 
own sake but for the good of others. Mere word knowledge 
about such things is largely worthless unless children live it 
in the home, school, and community. For example, children 
may and should be taught that there is danger in catching 
or communicating a disease through the common drinking-cup, 
but in addition to this the teacher must see that individual 
drinking-cups are provided and used. Every teacher should 
be able to teach children how to make a drinking-cup out of 
a piece of paper. 

(8) Instruction relative to the effects of tobacco and 
alcohol on bodily health has probably accomplished but little. 

iQ'Shea & Kellog's Health Series, and Coleman's "The People's Health" 
(Macmillan) ; Tolman's "Hygiene for the Worker" (American Book Co.), 
and Richard's "Hygiene for Girls" (Heath) are more recent texts of the 
new order. 



HYGIENE IN ELEMENTARY SCHOOLS ^6^ 

These topics when considered in the upper grades should 
emphasize particularly the economic and social loss to the 
person who has these habits. To tell boys that good football- 
players do not smoke, and that nobody who drinks can be an 
engineer or a conductor, is probably more effective in influ- 
encing action than to show the boys pictures of ulcers in 
the stomach due to the excessive use of alcohol. The most 
common arguments against temperance and total abstinence 
should be exploded by the presentation of scientific facts 
based on economics, good taste, and hygiene. 

(9) While a knowledge of sex hygiene is desirable for 
children, the ordinary teacher who has had no special scien- 
tific training, and has little or no sympathy with the matter, 
is not at all fitted to teach the subject with success, and the 
probability is that she may do more harm titan good. The 
proper place for this instruction is in the home. Teachers 
should lend their influence toward the distribution of good 
literature on such instruction to parents, and toward the en- 
couraging of meetings of parents where such matters can be 
talked over. Moreover, as more skilled teachers of nature 
study and biology are added to our schools, and as principals 
gain more scientific knowledge along those lines, the school 
may gradually meet these needs that are at present not 
satisfactorily met by all the homes. The present study and 
experimentation in this field promise much in the direction 
of increased socialization of the school. 

(10) Instruction in hygiene, to become effective, must 
plan to make pupils personally responsible. This responsi- 
bility cannot be expected unless the pupils are trained in 
habits that make for health. The school life of the child 
offers many opportunities for cultivating the right kind of 
action. Let us take a single example. Children who eat 
their midday lunches in the schoolroom are likely to leave 
much of the remains on the floor and desks. The teacher 
should insist on food remnants being properly taken care of 
until finally, through pupil organization if necessary, pupil 



366 EDUCATIONAL HYGIENE 

responsibility is assumed. ^ A schoolhouse and grounds that 
have been planned from the point of view of hygiene make it 
easier, of course, for the teacher to inculcate the right kind 
of habits. A poorly lighted, badly ventilated schoolroom, 
furnished with non-adjustable seats, and a muddy school- 
yard do not make for good habits. An investigation of the 
rural schools of Worcester County, Mass., conducted by the 
State Normal School at Worcester, shows that the hygiene 
and sanitation of these schools are deplorable. More exten- 
sive investigations, like the Ohio, Wisconsin, and Vermont 
school surveys, show that these conditions are common. 
But even under the most unfavorable conditions the ingenious 
and intelligent teacher can devise many ways for training 
the children in good habits. Floors may always be swept, 
furniture dusted, the window-shades adjusted, and the heat- 
ing and ventilating in some measure controlled. 

(11) In the selection of subject-matter, stress should be 
laid particularly upon the most important health problems of 
the commimity. The teacher in the rural schools should lay 
particular emphasis on topics in rural hygiene such as "The 
Danger of Infection from Surface Water, Springs," etc. A 
teacher in city schools would find topics like "Why It Is 
Better to Walk Short Distances Rather than to Take a Car" 
and "The Danger from a Leaky Gas-Tube," etc., more valu- 
able. One way of getting at these problems is to study the 
health needs of a given community, matters relative to water- 
supply, sewerage, etc., and how they are being met. The 
board of health of the community can frequently render 
valuable assistance by showing groups of pupils or teachers 
what are the unmet health problems of the community and 
what they can do to help in their solution. 

(12) The education of the children in hygiene demands 
the active co-operation of parents. Children cannot be made 
healthy through the mere training and instruction in hygiene 
given in the grades. The sanitary and hygienic conditions 

^ See Scott's " Social Education." 



HYGIENE IN ELEMENTARY SCHOOLS 367 

necessary for health must be supplied at home as well as at 
school. Hygienic habits, if they are really to influence the 
health of the children, must be not merely school but also 
home habits. School principals and teachers must see that 
the parents are enlightened as well as the children. The 
parent-teacher association movement which is now becoming 
so popular ought to be an excellent way of bringing parents 
and teachers together to co-operate for the health of the child. 
In such meetings physicians and nurses might be called upon 
to talk to and with parents on home hygiene.^ 

(13) The practise of hygiene should be fostered and ap- 
proved in much the same way as any of the required and im- 
portant work of the school. The teacher praises the child 
for excellence in arithmetic or geography and gives him a 
high mark on his report-card. Should not praijtise in hygiene 
be praised and marked in the same way? The practise of 
hygiene is of fundamental importance and it should have 
equal opportunities for success with the other subjects of 
the curriculum. I realize that this suggestion is radical and 
that our system of marking is defective; nevertheless, I be- 
lieve it would be a means of improving hygienic practise. 

IV. Methods of Teaching Hygiene. — (a) Incidental. — ^As 
previously suggested, we need to judge the results of the 
teacher of hygiene largely by the habits which she has been 
able to inculcate. In one sense the schoolroom, the school 
grounds, and the home are to be considered as places for the 
practise of hygienic habits. Every opportunity that the 
teacher has to help the cliild to form the right kind of habit 
should be eagerly seized. It is quite absurd to think of 
different habits, all important to health, being taken up in 
certain grades in a mechanical fashion and then being allowed 
to drop. It is not sufficient to mention cleanliness in one 
grade, or to make a great crusade for cleanHness at this time, 
and then let it drop and begin on another habit in the next 

1 Professor W. H. Heck, "Parents' Part in School Hygiene," Educational 
Review, February, 1914. See also Appendix II. 



368 EDUCATIONAL HYGIENE 

grade. It is well to remember, too, that there is no general 
habit of cleanliness. A child may have clean teeth and not 
have clean finger-nails. General cleanliness is gained only 
through the practise of specific habits of cleanliness and the 
development of propulsive health ideals. 

Instruction in and practise of habits necessary for health 
should take place as soon as the child enters school. In most 
cases this instruction should be incidental and individual. 
In some cases, as in the cleaning of the teeth, class instruc- 
tion should be given and tooth-brush drills inaugurated. As 
soon as the habit is being practised regularly, nothing further 
need be done except in individual instances. Sometimes the 
entire school may come from homes where they are taught 
to clean their teeth regularly. In such circumstances the 
teacher would not, perhaps, find it necessary to give the mat- 
ter much consideration. When lessons are given in the lower 
grades they should be brief, simple, and in a conversational 
tone. The first four grades should centre their forces on 
getting children to form essential habits and, eventually, on 
making the pupils responsible for them. Reading and a more 
systematic treatment of the subject should come in the 
higher grades. 

Among the many good habits which the teacher should 
supervise to a certain extent in the school are: (i) cleanliness 
of body and cleanliness in the schoolhouse and on the school 
grounds, (2) cleaning the teeth, (3) ventilating the school- 
room, (4) assuming correct postures, (5) correct breathing, 
(6) cleaning shoes before entering the schoolroom, (7) correct 
use of the voice, (8) right use of the eyes, (9) care of hair and 
nails, (10) use of individual drinking-cups, pencils, and other 
materials, (11) dusting school furniture, (12) cleaning black- 
boards, (13) use of the handkerchief, etc. 

There are also some bad habits which should be discour- 
aged, such as (i) putting things into the mouth, (2) expec- 
torating on the floor, (3) biting nails, (4) thumb-sucking, 
(5) "swapping" gum, food, etc., (6) coughing in another's 



HYGIENE IN ELEMENTARY SCHOOLS 369 

face, (7) kissing on the lips, (8) carrying soiled handkerchiefs, 
(9) picking the nose, (10) licking the fingers in turning the 
pages of a book, (11) reading in a dim light, (12) rubbing the 
eyes, (13) putting foreign bodies into the ear, (14) cracking 
nuts with the teeth, (15) overeating, (16) eating when tired, 

(17) using another person's brush, comb, towel, drinking-cup, 

(18) wearing wet clothing, (19) bandaging a cut with a dirty 
cloth, (20) wearing shoes that are too small, (21) negligence 
in bathing, (22) getting wet feet, etc. 

In the upper grades, say beyond the fourth, it is to be 
hoped that less and less effort will be necessary on the part of 
the teacher as the pupils assume more and more the responsi- 
bility. Incidental instruction, however, will always be neces- 
sary. 

Even if pupils practise certain habits whik at school, it 
does not necessarily follow that they will practise them at 
home; and then there are many habits, such as sleeping with 
the window open, that cannot well be practised at school. 
The teacher may advise children, ask them to report, or 
possibly confer with the parent to get the child to act. The 
deep-seated prejudice and ignorance found in many homes 
interfere greatly with the teacher's success in this direction. 
Often she can do little but give advice and hope that it will 
function. All associations which bring teachers and parents 
together to talk over common health problems should be en- 
couraged. 

The teacher in co-operation with a school physician and 
nurse may accomplish a great deal to make parents feel a 
sense of responsibility. As the school physician is not in 
direct contact with the children and carries certain authority 
because he is a physician, both the children and the parents 
in many cases are more likely to respond. If they do not, a 
school nurse may be sent directly to the home to advise the 
parents and to see personally that the children have proper 
care. To make the work of the school physician and school 
nurse effective, however, the teacher's intelligent co-operation 



370 EDUCATIONAL HYGIENE 

is necessary. She must be quick to see that there is something 
wrong and refer the case to the physician. The result .in 
most cases is likely to further the interests of school work. 
Often it is backwardness in school which suggests that there 
is something wrong with the health of the child. When that 
is corrected, the school work almost invariably improves. 
Whenever a child is backward without any apparent cause, he 
should always be turned over to the physician. 

The Massachusetts State Board of Education has issued a 
pamphlet which should be very helpful to teachers. The 
general symptoms which would justify sending a pupil to 
the school physician, according to this pamphlet, are as fol- 
lows: (i) emaciation, (2) pallor, (3) puihness of the face, 
(4) shortness of breath, (5) swellings in the neck, (6) general 
lassitude and other evidences of sickness, (7) flushing of the 
face, (8) eruptions of any sort, (9) a cold in the head with 
running eyes, (10) irritating discharge from the nose, (11) evi- 
dences of sore throat, (12) coughs, (13) vomiting, and (14) fre- 
quent requests to go out.^ 

All educators and physicians now realize, I believe, that 
the teacher should not attempt to diagnose a trouble; she 
should be able to recognize, however, that something is wrong. 
Normal-school students as a part of their professional work 
in hygiene should study the different ways in which they can 
co-operate with the medical inspector and nurse. Such a 
study should include in part the actual observation of the 
medical inspector and nurse at work, assisting where possible. 

Not only should the teacher co-operate with the medical 
inspector and nurse but she should also co-operate with chari- 
table institutions and the home so that sick or defective chil- 
dren may be properly cared for. As an illustration of the 
right kind of co-operative effort I quote from the records of 
the Elizabeth Street School, Worcester, Mass. : 

* See also list of symptoms given on page 215, 



HYGIENE IN ELEMENTARY SCHOOLS 37 1 

Winter of 191 2-13 

H., boy of thirteen years, anemic, nervous, undersized, with 
greatly enlarged glands, had grippe which left him with hard cough 
and in a weakened condition. His school work was so poor the 
teacher reported the case to the medical inspector, thinking that it 
might be best to take the child out of school. 

A tonic was recommended, milk and fresh eggs were obtained 
through the Anti-tuberculosis Society, and part-time attendance was 
permitted for the remainder of the year. At the request of the medical 
inspector and after a conference with the mother, this boy was taken 
to the City Hospital. An examination showed tubercular infection 
in one lung, and other symptoms. By appealing to a charitable or- 
ganization, an arrangement was made whereby he was sent to the 
country for the summer. 

H. returned to school in better condition than he has ever been in 
before; is doing good work in class, receiving the last term the best 
report he ever had. 

As a result of conferences with the mother, the boy is now able to 
sleep with his windows open and be out of doors a good deal. He is 
examined at intervals by the school physician, who reports that he is 
now in an excellent physical condition. 

Spring of 19 14: H. has entered trade school, is in good health and 
is doing good work. 

This is a kind of work in hygiene that counts. 

Medical inspection, if it is to further the health of the 
school-children, must do something besides *' inspect." It 
must follow up cases to see that they are properly treated. 
The ordinary notice sent to the parent, unless it is followed 
up as in the case mentioned above, is generally useless. 
Doctor Storey has demonstrated the value of a "follow-up 
method" in the secondary and lower collegiate department 
of the College of the City of New York. This plan of in- 
dividual instruction in hygiene, Doctor Storey says, proved 
effective in 90 per cent of the cases. Although there are 
probably many more obstacles in connection with an ele- 
mentary school, yet there is no reason why a similar method 
should not be employed with a great improvement over the 
present prevalent practise. 



372 EDUCATIONAL HYGIENE 

Another way of teaching hygiene incidentally, one which 
is seldom made use of, is to treat in the schoolroom all simple 
emergencies that arise. This should be done for the sake of 
the health of the children and to give them some valuable 
ideas on hygiene. Many children have no idea of antiseptics. 
If a cut or burn is treated in the school, such information 
may be given so that it may be remembered. There is no 
reason why children should not be taught how to bandage a 
finger or hand. When skill has been gained in doing this 
in a class exercise, they will then be able with the teacher's 
supervision to put on a bandage in an actual case of emer- 
gency. A simple emergency outfit can be purchased for a 
slight expenditure. One of these outfits should be on hand 
in every school-building, especially in a rural school-building 
where the home and physician are often some distance away. 
An inexpensive emergency outfit which can be purchased at 
any good drug-store is indicated below: 

Emergency Outfit 

Bandages, one-inch, for fingers and toes, 30 cents a dozen; one-inch, 
for extremities, 40 cents a dozen. 

Absorbent cotton, 27 cents a pound. 

Sterile gauze pads, for use as sponges or as wet dressings, one 
dozen in a package, 30 cents. 

Zinc oxide adhesive plaster, to draw edges of cuts together and 
hold dressings on, one-half inch by ten yards, 40 cents a roll. 

Flexible collodion, one-ounce bottle with brush to apply, 18 cents. 

Creolin, Pearson's, one pound, 75 cents. (One teaspoonful in one 
pint of water makes antiseptic solution.) 

Tincture of iodine, two ounces with brush to apply, 10 cents. 

Aromatic spirits of ammonia, four ounces, about 25 cents. (For 
faintness, fifteen drops in a tablespoonful of water. Repeat in five 
minutes if necessary.) 

Carron oil, six ounces, about 20 cents. (Apply to bums.) 

Witch-hazel, six ounces, about 20 cents. (For sprains.) 

Borax, 5 cents. 

Oil of cloves, two ounces, 20 cents. 

Rubber hot-water bottle. A common-size glass bottle is as good 
and far cheaper. 



HYGIENE IN ELEMENTARY SCHOOLS 373 

Safety-pins, small and large. 

Scissors. 

May have in addition: 

Essence of peppermint. (One-half teaspoonful in one-half cup of 
hot water for colic, or a pinch of red pepper in hot water.) 

Soda bicarbonate tablets, gr. v. (For sour stomach and vomiting.) 

Spirits camphor. (To rub on swellings where skin is unbroken.) 

This complete outfit can be purchased at any good drug-store for 
about $4. If conditions make this expense impossible, every teacher 
may have a simple outfit to treat cuts, burns, and bruises for a small 
sum. It should be put into a substantial wooden box and kept under 
lock and key. 

Two books of invaluable assistance to every teacher in dealing 
with emergencies are: "Emergencies," Gulick, "Hygiene Series," 
(Ginn & Co.); Barton, "First Aid Text-book" (published by First- 
Aid Association of America, Boston). 

Incidental instruction, which may not be directly related 
to immediate action, should also be touched upon in other 
lessons. Health is so related to all the experiences of life 
that it may be considered in this fashion without a thought 
of "dragging it in." Let us note a few examples. In his- 
tory, children should be taught to perceive the progress that 
has been made in overcoming disease, new discoveries in 
medicine and hygiene, and the effect of these on society; in 
civics, activities pertaining to public health, such as the 
cleaning of the streets, the disposal of garbage, and the pre- 
vention of the spread of disease, should be emphasized; in 
geography, the failure or success of man to conquer his en- 
vironment through the neglect or practise of modern sanita- 
tion is important, such, for example, as the French and 
American methods at Panama; in nature-study, many oppor- 
tunities are offered to teach the structure and functions of the 
human body by comparing man with the plant and animal 
world. Knowledge thus gained helps to make the child feel 
the importance of health. 

(b) Systematic Instruction. — It is only fair to ask why, if 
habit is the real goal of instruction in hygiene, systematic in- 
struction needs to be given. Personally, I believe there is 



374 EDUCATIONAL HYGIENE 

little place for it below the fourth or fifth grades, and not even 
in the higher ones iinless it centres about the interests of the 
children. In the upper grades its purpose should be that of 
supporting the hygienic habits which the children are learning 
or have learned. It should also give them some sort of an 
appreciation of health as one of the assets of our civilization. 
This general purpose of appreciation must be characteristic 
of much that is taught in our public schools. For example, a 
large proportion of the children who study about the mining 
of coal or the manufacture of steel will never make their 
living in those industries, and coal would burn just as well 
without any knowledge of how it came into being. A knowl- 
edge of both coal and iron does help to broaden the social 
consciousness of the child. It enables him to see these in- 
dustries in relation to the needs and achievements of the 
people. 

For a similar reason systematic instruction in hygiene 
should be given, only in this case hygiene is much more im- 
portant as a social problem and is something which the citizen 
can influence to a large extent by his voice and vote and action. 

Fortunately, at this time there are a number of good text- 
books in hygiene available for children in the grades. Among 
such books the GuHck "Hygiene Series" (Ginn & Co.) seems 
to the writer to be most interesting to children. In this brief 
paper it is impossible to discuss the ways in which such books 
can best be used. Every teacher should have on hand a few 
books for ready reference. The busy teacher who wishes to 
get a general background of physiology and anatomy with their 
application to hygiene will find Coleman's "Hygienic PhysioL 
ogy " (Macmillan) excellent. A larger and heavier work along 
the same lines is Hough and Sedgwick's "The Human Mech- 
anism" (Ginn & Co.). Every teacher should have on her 
desk a good book on school hygiene. Hoag and Terman's 
"Health Work in the Schools" (Houghton, Mifflin) and Dress- 
lar's "School Hygiene" (Macmillan) are probably the best. 
Terman's "The Hygiene of the School Child" (Houghton, 



HYGIENE IN ELEMENTARY SCHOOLS 375 

Mifflin) is almost indispensable. Ditman's '' Home Hygiene 
and the Prevention of Disease " (Duffield) is probably the 
best book to recommend to parents. 

Besides such material, which may be permanently avail- 
able, the current newspapers and magazines contain abundant 
material which the teacher may inject into the lessons. Some 
of the magazines have excellent pictures in their regular 
reading columns or in the advertising section, which may be 
used effectively. In the upper grades the teacher may find 
it advantageous to have a bulletin-board on which the chil- 
dren may put printed matter of interest. 

The tendency in teaching hygiene, as in all other subjects, 
has been to emphasize the acquisition of mere knowledge. 
This is, of course, to be deplored. Subject-matter should be 
selected with reference to its probable po\|fer to promote 
healthy ideals, practical knowledge, and, most important of 
all, habits necessary for health. In the last analysis the 
value of the work in hygiene must be judged by the number 
and value of the hygienic habits which pupils have formed. 

V. An Effective Ideal of Health. — ^The psychology of 
ideals is still a dark chapter in our modem psychology. Many 
teachers and parents are misled in the belief that mere word 
knowledge, even when coupled with considerable understand- 
ing, functions through ideals. A child may have a good deal 
of knowledge about the structure, function, and care of his 
teeth and still never use a tooth-brush. Knowledge is use- 
ful in inculcating the right habits but it is insufficient. The 
idea of the care of the teeth must have back of it a desire to 
have clean teeth, otherwise the child's knowledge becomes 
mere formal intellectual propositions. Knowledge presented 
so as to touch the child's interests and ambitions does fre- 
quently function, but our effective ideals probably develop 
in most cases through habits of action. It is questionable 
whether many gain the ideal of work after knowing the value 
of work. The effective ideal of work usually comes through 
habits of industry. Likewise ideals of cleanHness are acquired 



376 EDUCATIONAL HYGIENE 

through habits of being clean. The first step toward getting 
children to develop the ideals of health is to get them to form 
the right habits. Attractive knowledge of the right kind will, 
of course, tend to make the practise of the habit easier. The 
inspiration and example of the teacher, too, are always pow- 
erful incentives to habit-formation. Out of these hygienic 
habits, ably supported by a knowledge of the value of hygienic 
living, there should grow an effective ideal of health for the 
pupil who is to be thrown on his own responsibility in facing 
the problems of life. 

VI. Suggestions for Teachers.^ — (i) The conservation and 
improvement of the health of the children should be your first 
consideration. 

(2) Make the hygiene and sanitation of the school house 
and grounds as satisfactory as possible. 

(3) Try to improve the home conditions under which the 
children live by getting the co-operation of the parents. 

(4) Give the children information incidentally whenever 
needed. Systematic instruction should be given in the 
upper grades. 

(5) Present information that is allied to the child's in- 
terests. If the subject-matter is not in itself attractive, 
associate it with something that is of interest. Appeal to 
some incentive that will make pupils anxious to gain more 
knowledge of the subject. 

(6) Teach only the anatomy and physiology that are neces- 
sary to enable the pupils to practise hygiene better and to 
give them a common-sense idea of the structure and functions 
of the body. 

(7) Subject-matter should be chosen with reference to in- 
spiring health ideals and the promotion of the practise of 
hygiene. 

(8) Get children to study the sanitary and hygienic prob- 
lems of the community and its success or failure in their 
solution. 

(9) Study the individual children to discover any symp- 



HYGIENE IN ELEMENTARY SCHOOLS 377 

toms of illness or physical defects. Promptly refer such 
cases to the school physician, nurse, or parents. 

(10) Follow up every case to see that it is properly treated. 
If necessary, get the assistance of the home or charitable or- 
ganizations. 

(11) Train the children in hygienic habits in the school 
Try to get the children to practise specific habits at home by 
securing the co-operation of the parents. 

(12) Get the child to put into practise his knowledge of 
hygiene whenever the opportunity presents itself. 

(13) Carefully supervise every habit in the early stages of 
its formation. Insist on practise until the act has become 
automatic. 

(14) Plan to make the pupils eventually responsible for 
the practise of certain specific habits. » 

(15) In approving or disapproving the child's work in 
hygiene always consider the practise of hygiene. If you 
mark the child for his knowledge of hygiene, mark him also 
for his practise. Practise is more important than knowledge. 

A Health Programme for Country Children.^ — In their ef- 
forts to improve hygienic conditions in the schools and in 
the community, teachers frequently find some assistance in 
a simply worded health programme or creed for the indi- 
vidual child to apply to his own experience. The follow- 
ing is not intended as a final or exhaustive statement of 
such a programme, but it is believed that by means of it 
the rural teacher may be able to drive home certain fun- 
damentals in hygiene and sanitation that will ultimately 
mean much for good health in home, school, and community 
and make a direct contribution to the movement for better 
schoolhouses in the country. It is assumed that the teacher 
will select such of these items as seem most useful for her 
purpose and supplement them with illustrative examples 
from real life. 

*By Professor ±<', B. Dresslar, from his government bulletin 00 Sanitary 
Schoolhouses and Grounds. 



378 EDUCATIONAL HYGIENE 



LEST I FORGET 

I believe that good health and a strong body are essential, and 
that the only real wealth is good health. In order that I may be 
strong and well, therefore, I will endeavor to observe the following 
rules of health: 

1. I will keep my teeth clean by using my tooth-brush every day. 

2. I will drink no coffee or tea before I am twenty years of age, 
and no sort of alcoholic stimulants at any time in my Hfe, unless 
ordered to do so by a physician. 

3. I will chew my food thoroughly. 

4. I will sleep at least nine hours each night in well-ventilated 
rooms winter and summer, or in an open-air sleeping porch. 

5. I will bathe my whole body at least once a week and keep 
my face, hands, and nails clean. 

6. I will strive daily to acquire a habit of self-control, habits of 
anger being not only wrong but unhealthful. 

7. I will strive to help make my home as clean and sanitary as 
possible, especially to prevent contamination of the milk and drinking 
water. 

8. I will do all I can to prevent the development of flies about 
the house in which I live, since they carry the germs of typhoid fever 
and other diseases. 

9. I will do all in my power to prevent mosquitoes from breeding 
in or about the house I live in. I will bury or destroy aU old tin 
cans, barrels, or other vessels which catch and hold rain water and 
offer a place for mosquitoes to breed. I will help to drain all stag- 
nant pools near my home or put kerosene oil on them once every 
ten days during summer. 

10. I will try hard to kill all rats and mice about my home, since 
they are both troublesome and dangerous, carrying, among other 
things, the bubonic plague, one of the most deadly of all diseases. 

11. I will do all in my power to help secure sanitary toilets through- 
out the whole neighborhood. 

12. I will strive to keep the back yard of my house as clean and 
tidy as a front yard should be kept. 

13. I will take no patent medicine, and will do all I can to teach 
people that most of it is both useless and harmful. 

14. I will keep my personal life clean and pure, for it is a duty 
I owe to myself and to all who live now and may live in the future. / 

15. I will take good care of my eyes, taking special pains not to 
strain them by reading at night or in bad light. 



HYGIENE IN ELEMENTARY SCHOOLS 379 

16. I will be careful about spitting, since disease is often spread 
in that way. 

17. I will do all I can to help make our schoolhouse more attract- 
ive and to keep it clean and neat at all times. 

18. I believe the best investment I can make for myself and my 
family is to invest in good health, a good education, and a clean moral 
life. 

19. I will strive with all my power to make country life more 
healthful, more enjoyable, and more beautiful. I beheve life in the 
country is finer and better than life in any city. 



CHAPTER XXI 
HEALTH TEACHING IN HIGH SCHOOLS 

The Need for Teaching Hygiene. — The great Erasmus 
thought that natural history should be taught in the schools 
in order that the pupils might understand the allusions in Vir- 
gil and the other classic poets to flowers, animals, and other 
objects in nature. A distinguished medical practitioner a 
few years ago urged the teaching of physiology and hygiene 
in high schools in order that ''patients might understand 
their physician better; might tell him better about their ail- 
ments when afflicted." Both Erasmus and this modern 
physician had an eye to direct utility, but it was an illusory 
utility characteristic of intellectual astigmatism. The reasons 
for the study and teaching of health in our high schools are 
as much broader and more fundamental than the reason al- 
leged by the physician as were the reasons for studying 
natural phenomena broader and more fundamental than the 
reason alleged by Erasmus. In both cases the real reason is 
the value of the thing itself. 

In the light of the economic and ethical relations of 
health,^ its place in education takes on a new significance. 
Conservation of health is an essential end of education. In 
the elementary school this end is attained if right habits of 
living are initiated. In the high school something more is re- 
quired. High-school pupils should acquire an imderstanding of 
basic principles of hygiene, both personal and social; and the 
organization of health instruction and health practise in the 
high schools should be definitely to that end. This does 
not imply that the work of habituating to right living will 

* Rapeer, " School Health Administration," chap. I» 
380 



HEALTH TEACHING IN HIGH SCHOOLS 38 1 

have been completed in the elementary schools. For two 
reasons this is impossible : first, because habits wait upon in- 
stincts and capacities, and some instincts and capacities do 
not mature in the elementary school age; second, because the 
administration of health measures, even in the best elementary 
schools, is so far from perfect that a large part of the pupils 
still pass through without acquiring a full set of habits of 
right living. Not only is the health teaching very imper- 
fect, but also the home environment is frequently not con- 
ducive to the formation of health habits. "More than 95 per 
cent of our public-school pupils come from homes where, for 
one reason or another, they fail to learn some things pertaining 
to their bodily welfare that every person ought to know."^ 
It is not surprising, therefore, that a large per cent of high- 
school entrants are short on habits of right Mving. In the 
high school there is much to be done in the way of forming 
right habits. But beyond this is the necessity of vitalizing 
habit and prescription by an understanding of the laws and 
principles of hygiene. 

Status of Health Teaching in the Elementary School. — 
The problem of health teaching in the elementary school is 
fully treated in the preceding chapter, but as the character of 
health teaching in the high school depends in a measure upon 
the character of the health teaching in the elementary school, 
a brief reference to that matter is necessary in this connec- 
tion. In Massachusetts, for near a hundred years, the neces- 
sity of health teaching in the public schools was agitated 
intermittently. Results were meagre and unsatisfactory.^ 
It was not imtil 1885, under the stimulus of the "scientific 
temperance" propaganda, that the teaching of health became 
compulsory by statutory enactment. With local variations 
of time and emphasis, the history of Massachusetts is the 

1 Moseley, "Some Ways of Teaching Practical Hygiene," School Science and 
Mathematics, January, 191 2, p. i /. 

2 Towne, Lillian H., "Problems of Teaching Hygiene," U. S. Bureau of Ed- 
ucation Bulletin No. 48, 1913, "School Hygiene," p. 74. 



382 EDUCATIONAL HYGIENE 

history of most of the other States. This propaganda aimed 
at "temperance," not at physiology. "In all grades below 
the high school this instruction should contain only physiology 
enough to make the hygiene of temperance and other laws of 
health intelligible. Temperance should be the chief and not 
the subordinate topic and should occupy at least one-fourth 
of the space in text-books for these grades.'' ^ Within fifteen 
years practically every State in the Union had enacted laws 
requiring the teaching of physiology and hygiene, "with 
especial reference to alcohol and narcotics," in all the ele- 
mentary public schools. 

The failure of the movement is generally conceded, and 
the reasons for failure have been abimdantly set forth.^ It 
aimed to prevent the use of alcohol and tobacco by teaching 
early the harmful physiological effects of these drugs. In 
its fervor for the cause it sadly mixed myth and science, 
sought to base concrete practise upon scientific understanding 
instead of the reverse, and preached the doctrine of fear and 
negation. The increased per-capita consumption of both 
alcohol and tobacco in the generation during which "scientific 
temperance instruction" has had place in the schools is suffi- 
cient proof of the failure of the specific aim of the movement. 

The success of the movement, however, has not been 
generally recognized. This movement carried within itself 
two factors pregnant of results. Firstj it had the dynamic 
force of a moral idea. The moral earnestness of the "scien- 
tific temperance" propaganda that within half a generation 
wrote its laws upon the statute-books of practically every 
State in the nation, and then enforced obedience to those laws, 
is now coming to expend itself in the safeguarding of the 
health of school-children and in developing a kind of health 
instruction that shall build up habits of hygienic living and 
create a health conscience among the children. 

* Billings, J. S., "Physiological Aspects of the Liquor Problem," 1903^ 
vol. I, p. 23. 

2 Berry, Charles Scott, "High School Education," ed. by Charles Hughes 
Johnston, p. 347/. (Scribners, 1912). 



HEALTH TEACHING IN HIGH SCHOOLS 383 

The second factor is found in the declaration of principles 
quoted above: "This instruction should contain only physiol- 
ogy enough to make the hygiene of temperance and other laws 
of health intelligible J ^ Here was a declaration of radical im- 
portance. ''Naming the bones" has been the butt of many a 
jest on the part of the critics of the old text-book physiology; 
but up to the time of the "scientific temperance" movement 
no better doctrine had been formulated either by pedagogists 
or scientists. The principle was not observed in the " scientific 
temperance" text-books. For the most part, "temperance 
physiology" was merely grafted upon the old books and old 
methods. But the germinal idea had been foimd and it was 
the "scientific temperance" zealots that "fished the murex 
up," not their critics. The substantial principle of health 
instruction in the grades is increase of health, ^The methodo- 
logical principle is subordination of anatomical and physio- 
logical fact to the laws of health. In only a few of the best 
schools does the teaching of health conform to these prin- 
ciples, but almost universal lip-service shows the direction of 
the wind. Text-books are appearing that embody these prin- 
ciples.^ With the ideal well recognized and with adequate 
teaching material available there is no excuse for the per- 
sistence of outworn matter and methods. In writing of health 
teaching in the high school one may assume that the elemen- 
tary school in the next few years will fulfil reasonable require- 
ments.2 

* It may not be invidious to mention the series by Gulick (Ginn & Co.), 
Woods Hutchinson (Houghton Mifflin Co.), Coleman (The Macmillan Co.), 
Bibb and Hartmann (The World Book Co.). In these books the laws and 
practises of hygiene are made intelligible; there is abundance of illustrative 
data; in some there is a good deal of simple experimental material; commu- 
nity hygiene is recognized and emphasized; anatomy and physiology are sub- 
ordinated to hygiene. 

2 In this discussion the orthodox-organization eight-year grade and four-year 
high school is assumed. The next ten years will see a rapid modification of 
this scheme. (See "Economy of Time in Education," Bulletin No. 38, 1913, 
of the U. S. Bureau of Education.) The reorganization of the higher grades of 
the elementary school will make possible a much more effective teaching of all 
subjects than is possible under the present organization. 



384 EDUCATIONAL HYGIENE 

The High School and Community Leadership. — ^The Amer- 
ican high school is our most interesting educational institu- 
tion not only because of its essential character, ''more demo- 
cratic than the college and more selective than the elementary 
school," wherein "manhood and womanhood are visibly 
budding," but also because of its unprecedented growth and 
expansion during the past two decades. In 189 1-2 there 
were in the United States 4,158 schools of secondary rank, 
16,329 teachers, and 297,894 pupils.^ In 1911-12 the numbers 
were, respectively, 13,268 schools, 64,236 teachers, 1,246,827 
pupils.2 This is an increase of more than 300 per cent in the 
number of pupils. The average annual increment is nearly 
50,000. Even more striking is the acceleration of increase in 
the last four years of the series: 72,000 in 1909, and 131,501 
in 191 2. The increase in 191 2 is 50 per cent greater than the 
average of the three years next preceding, and more than three 
times as great as the average of the preceding twenty years. 
The proportion of high-school pupils to the total school 
population has increased threefold in that time. About 23 
per cent of the children of the present generation receive some 
high-school education. There is also a slow but steady in- 
crease in the number of pupils who persist through the four 
years of high school. In 1906-7 there were 89,882 pupils, or 
12^ per cent, in the fourth year; in 1911-12 there were 166,- 
266 pupils, or 13^ per cent. In 1890 the high-school students 
were slightly less than one-half of one per cent of the total 
population of the country; in 191 2 a little more than 1.3 per 
cent.^ 

The significance of these figures lies not in the facts of 
increase but in the potential community leadership of this 
rapidly increasing part of the body politic that receives the 

^ " High School Education," ed. by Charles Hughes Johnston, Introd. 
(Scribners). 

2 Rep, United States Com. Ed., 1912, vol. 2, chap. 8. 

^ Assuming that the annual increment in population in 191 1 and 191 2 is 
about the same as for the two decades preceding. 



HEALTH TEACHING IN HIGH SCHOOLS 385 

impetus of high-school education. The impact upon society 
of this stream of high-school- trained citizens becomes inevi- 
tably more massive. Whether it shall be effective in propor- 
tion to its mass depends upon the character of the high-school 
training. Whether it shall raise the health standards of the 
community in proportion to its possibilities for such service 
depends upon the emphasis that is placed in the high school 
itself upon the practise and the study of health. It is possible 
for the high school to ignore both the practise and the teach- 
ing of hygiene; it is possible for bad practise to nullify good 
instruction; it is also possible for practise and instruction to 
co-operate in safeguarding and promoting the vitahty of 
pupils, and in enlightening their understanding with respect 
to the significance of public and personal hygiene. Not the 
least of the problems of the ''new" high ^chool is this of 
building up a public- health conscience. 

The Physical Conscience. — It has been pointed out many 
times that the worship of Hygeia, so characteristic of the Greek 
civilization, and so repugnant to the early Christian culture, 
has revived within the last half-century. The modern at- 
titude toward health is something more than admiration for 
physical strength, grace, and beauty. It involves also the 
idea of duty, the duty of realizing in oneself the physical 
virtues of strength, efficiency, and endurance. These are es- 
sential to the achievement of the "aesthetic, intellectual, and 
spiritual development to which our own age aspires." ^ It is 
the idea of duty in this conception that justifies us in speaking 
of "the physical conscience." It is the development of the 
physical conscience that is the special task of health instruc- 
tion in the high school. Obviously the physical conscience 
cannot be a resultant of the study of quadratic equations, 
Latin declensions, and Burke's orations; it must be the re- 
sultant of hygienic environment, habituation to the practises 
of hygienic living, and an understanding of the principles of 
hygiene. 

* Ibid., p. 346.. 



386 EDUCATIONAL HYGIENE 

The Physical Status of High-School Pupils. — ^How much 
the development of the physical conscience is needed is ap- 
parent when one investigates the physical status of high- 
school pupils; and even more, perhaps, when one examines 
their health ideas and ideals. The records of physical ex- 
amination show a large amount of defect and ailment among 
high-school pupils; examination of their health ideas and 
ideals shows an appalling amount of ignorance of both per- 
sonal and public hygiene and an equally appalling amount 
of complacency with respect to ill health. Many exhibit an 
almost fatalistic acceptance of physical inferiority. They 
recognize neither the disgrace of being weak nor the duty of 
being strong. 

Casual observation of high-school pupils shows a surpris- 
ingly large amount of physical imperfection. Careful phys- 
ical examination fully confirms casual observation. Recent 
records of physical examinations in Newark, N. J.,^ and Wash- 
ington, D. C.,^ are probably typical. 

In Newark during the years of 1911-12 and 191 2-13 prac- 
tically aU of the high-school pupils of both sexes were given 
systematic and thorough physical examination. The Wash- 
ington record is of 284 girls in the Eastern High School of that 
city. In Newark the physical examination showed the fol- 
lowing results for the two years: 

Average number of pupils examined 2,186 

Average number of pupils normal 802 

Average number of pupils with defects 1,384, or 63 per cent 

The average total number of defects for the two years 
was 2,204, distributed as follows: adenoids, nasal obstructions, 

iRapeer, in "The Modern High School," ed. by Charles Hughes Johnston, 
chap. XXVII. 

2 Small, W. S., "Some Results of Systematic Physical Examination of High 
School Pupils." Proceedings Fourth International Congress on School Hygiene, 
1913. (Reprinted in The School Journal, January, 1914.) 



HEALTH TEACHING IN HIGH SCHOOLS 387 

etc., loi; defective hearing, 103; dental defects, 740; enlarged 
tonsils, 298; visual defects, 555; enlarged glands, 17; heart 
defects, 102; weak lungs (not tuberculous), 22; malnutrition 
and debihty, 78; mentally defective, i; nervous affections, 5; 
defective palate, 8; orthopedic, skeleton, chest, 42; spinal de- 
fects, 19; speech defects, 5; all skin ailments, no. 

According to these figures two-thirds of the high-school 
pupils in Newark are physically defective. This does not take 
account of about thirty classes of ailments not reported in the 
returns. This is a larger percentage of defect than is found 
among elementary- school pupils, according to Doctor Rapeer.^ 
It is probable that there is exaggeration in the Newark figures 
of the number of cases of defective hearing, defective vision, 
enlarged tonsils, heart defects, and orthopedic defects. The 
ratio of these per 1,000 pupils is so much greater for these 
high-school pupils than for elementary-school pupils, as 
estimated by Doctor Rapeer, upon the basis of extensive and 
carefully analyzed data, that the presumption is against the 
accuracy of the figures. 

In the case of vision the exaggeration is obvious, as the 
"standard for defective vision is fixed at 20/30 instead of 
20/40, which permits the recording of many minor cases of 
defective vision that are not referred for glasses." It is 
likely that the same is true also of the other types of defect. 
On the other hand, it is not improbable that the examination 
of these high-school pupils is more thorough than that or- 
dinarily given to elementary-school pupils. 

The physical-examination record of 284 girls in the Eastern 
High School of Washington in 191 2-13 shows general corre- 
spondence with the Newark record. These students had been 
in school from one to four years. The munbers are much 
smaller than the Newark numbers; only girls are concerned; 
and the examination was a physical rather than a medical 
examination. On the other hand, the examinations were 
semiannually repeated. The girls were continuously under 

1 Ihid., p. 686. 



388 EDUCATIONAL HYGIENE 

observation, and medical examinations were made in doubt- 
ful cases. The examination records were supplemented by 
notes of observations. They are a fuller chart of the health 
of the individuals concerned than are the Newark records. 
Of the 284 girls, 168 girls, or 59 per cent, had defects of 
some kind — 59 per cent as compared with 63 per cent in New- 
ark. These 168 girls had a total of 378 defects, an average of 
more than two each. The recorded defects were distributed 
as follows: eyes, 93; ears, 24; spine, 30; heart, 29; lungs, 2; 
nose and throat, 19; enlarged glands, 26; developmental, 48; 
carriage, 71; ankles, 36. 

These two sets of figures show a large amount of defect 
and ailment among high-school pupils. The type and fre- 
quency of ailment found in the high school and the elementary 
school are similar, and point to an urgent need of enHghten- 
ment of high-school pupils with respect to health. 

The significance, however, of figures in regard to the de- 
fects of high-school pupils Kes not chiefly in the prevalence 
and distribution of defects; it lies rather in improvement and 
improvability. The correction of defects and the improve- 
ment of health during the high-school course are evidence at 
once of effective health teaching and of the development of 
the physical conscience. The persistence of remediable de- 
fects may be no reflection upon the teaching, but it is in- 
fallible evidence that the physical conscience has not been 
aroused. 

The Newark records show nothing in this connection. In 
the Washington school the record of corrections is as follows: 
Of the 378 defects recorded for 168 girls cited above, 116 
defects, or 30 per cent, had been corrected at the end of 1913; 
and of the 168 girls with defects, 88, or 52 per cent, had had 
some defects corrected. One-half of the defects of the fourth- 
year class had been corrected; one-eighth of those of the first 
year. Thirty-five girls who had been continuously in the 
school for four years show the following record of correction 
of defects: 



HEALTH TEACHING IN HIGH SCHOOLS 



389 



Year 


Number of girls 
with defects 


Total Number of 
defects 


Number of defects 
corrected 


I 


35 
32 
29 
28 
35 

25 


72 
61 
56 

45 
79* 

40 


13 

7 
II 

8 
39 

39 


II 


Ill 


IV 


Total 


Number at end of 
fourth year 



* Seven new defects were discovered after the first year. 

The progressive correction of defects is noticeable. In 
this fourth-year group, 50 per cent of the defects were cor- 
rected and 30 per cent of the defectives were improved. 

On the other hand, the number of remediable defects not 
remedied is eloquent testimony to failure. In case of the 
35 girls above mentioned, there were 40 xmcorrected defects; 
only 6, or 15 per cent, were irremediable. In all other cases, 
the pupils didn't care enough about health to pursue faith- 
fully the regimen that would have corrected the defect. Oc- 
casionally the mental, mind-stuff theory of disease stands in 
the way. In some cases, it is the vulgar fatalism that ac- 
cepts defect as a matter of course. More frequently, it is 
mere thoughtless indifference — don't want to take the trouble. 
In still other cases, vanity rebels against the necessary pre- 
scriptions as to clothes, shoes, glasses, etc. Unhygienic hab- 
its of life in some instances are so deeply rooted that a com- 
plete revolution in respect to diet, dress, sleep, exercise, and 
work would be required. There is no physical conscience, 
no appreciation of either the beauty or duty of health. 

Status of Health Teaching in the High School. — Both in 
character and extent the present status of health teaching in 
the high school is unsatisfactory. In 19 10 Doctor Gulick^ re- 
ported that of 2,392 representative high schools throughout the 

1 Gulick, L. H., "Report on Status of Physical Education in Normal Schools 
and High Schools," Proceedings Fourth Congress American School Hygiene 
Association, 1910, p. 174. 



390 EDUCATIONAL HYGIENE 

country, only i6 per cent gave regular instruction in hygiene 
and only 6 per cent had physical examination of pupils. In 
II per cent, instruction in hygiene was compulsory. Studies 
by Crosby^ and Hunter ^ show that physiology and hygiene 
in many schools are taught only in the first year of the course, 
prior to the study of any basic science. The method and 
matter are merely a rehash of elementary-school instruction. 
In general, the subject does not command either the interest 
or respect of the pupils. The case with physical training is no 
better. Doctor Gulick's report shows that only 8 per cent 
of the high schools gave regular instruction in gymnastics. 
In most cases the instruction is formal and involves little 
collateral teaching of hygiene. 

There are, however, encouraging signs. In a few States 
health instruction is compulsory in high schools as well as in 
elementary schools, and the number is increasing. The rapid 
growth of medical inspection of schools and the development 
of medical inspection into health supervision, with a complete 
programme of health promotion and control in all the public 
schools, is giving a new impetus to health teaching in the 
high schools. The organization of health instruction in high 
schools is making progress. There is still need for propaganda, 
but the important problem is the content and method of 
health instruction. 

Lack of College Credit. — It is alleged that failure of col- 
leges to give entrance credit for physiology and hygiene is 
one reason for the neglect and inefficiency of the teaching in 
the high schools. This is probably true, as the high school 
has been and still is strongly influenced by college-entrance 
requirements. In general, subjects have been legitimized in 
the high-school course by college favor. Other subjects have 
come in as poor relations and have been nurtured accordingly. 

^ Crosby, Clifford, "Physiology, How and How Much?" School Science and 
Mathematics, vol. 7, 1907, p. 738. 

2 Hunter, G. W., "Biological Science in Secondary Schools," School Science 
and Mathematics, vol. 5, 1910, p. 3. 



HEALTH TEACHING IN HIGH SCHOOLS 391 

Three factors, however, are Hkely to effect a change with 
respect to hygiene. The first of these is the essential impo*r- 
tance of the subject itself. From the practical standpoint its 
importance is recognized by those colleges which now demand 
a physical examination as one of the evidences of fitness for 
college entrance. As soon as it is recognized that systematic 
instruction in physiology and hygiene has practical relations 
with health habits and ideals, there will be a more hospitable 
attitude on the part of the colleges. The second factor is 
germane to the first — the colleges are rapidly coming to recog- 
nize the necessity and the potency of health instruction in 
college. The necessity is frequently attributed to the failure 
of the lower schools to provide such instruction, which is, of 
course, a confession that the high school ought to provide it. 
*'In 1884 hygiene was taught in 61 per cent of the 46 leading 
colleges. In 1909 it was taught in 84 per cent of the 116 
leading colleges." At the present time ''80 per cent of the 
colleges offering regular courses in hygiene give positive credit 
for these courses toward the bachelor's degree." The tend- 
ency is for all college subjects, that are within the capacity 
of the early adolescent mind, to gravitate, sooner or later, into 
the secondary school. Obviously hygiene is of this class. 
The third factor is the growing tendency of colleges to accept 
for entrance credit any high-school subject that is valuable and 
well taught. Successful teaching of hygiene in strong high 
schools will be cogent argument for college- entrance recog- 
nition. On the other hand, recognition by the colleges would 
be a powerful stimulus to sound teaching of hygiene in the 
weaker and more timorous high schools. For the sake not 
only of the high school but also of its own higher efficiency, 
the college should encourage this teaching by granting en- 
trance credit. 

The Locus of Health Teaching in the High-School Course. 
— ^The aim of health teaching in the high school as stated by 
Doctor Berry is "to give the pupil a scientific knowledge, as 
far as possible, of the principles of physiology, hygiene, san- 



392 EDUCATIONAL HYGIENE 

itation, and physical education, with a view to their practical 
application. But if this aim is to be realized the pupil must 
have acquired some knowledge of biology, and should also 
have studied^ chemistry and physics before beginning the 
proposed course in physiology and hygiene.'' ^ This means, of 
course, that this subject must be placed as late as the third 
year of the course; and, as most high-school courses are or- 
ganized, it must be placed in the fourth year. 

This is partly right and partly wrong. That the knowledge 
acquired by pupils in such a course should be *' scientific as 
far as possible," is self-evident. That instruction in hygiene 
and physiology must be delayed imtil late in the course on 
the groimd that the study of biology, chemistry, and physics 
is a prerequisite, is probably both impractical and unnecessary. 

The plan presupposes that these three sciences are pre- 
scribed for all pupils. This may be desirable, but there is 
slight probabiHty of the general adoption of such a prescrip- 
tion. Even were it adopted, there would still be the objection 
that only a minority of liigh-school pupils would be reached. 
In 1906-7 the distribution of high-school pupils for the nation 
was as follows: fourth year, 12.25 per cent; third year, 18.17 
per cent; second year, 27.23 per cent; first year, 42.35 per cent. 
There is a constantly increasing persistence of high-school 
pupils, as is shown by the corresponding figures for the year 
1913-14: fourth year, 14.27; third year, 18.84; second year, 
26.75; first year, 40.14.2 Allowing for factors other than 
mortaHty, it is certain that even now less than one-half the 
pupils who enter high school ever reach the fourth year. If 
instruction in physiology and hygiene is as important as we 
have contended, then it is imperative that all high-school 
pupils should have the benefits of such instruction. This is 
recognized by those States which require this teaching in 
the first high-school year. There must be health instruction 
in the first year, but this does not exclude further instruction 

^ Ibid., p. 357. 

*U. S. Bureau of Education, Statistics of Public and Private High Schools. 



HEALTH TEACHING IN HIGH SCHOOLS 393 

in subsequent years. There should be continuous teaching of 
health, collaterally and incidentally, in all the years of the 
course; and there should be in the last year a systematic 
course in physiology, anatomy, and hygiene utilizing the 
knowledge of the basic sciences that may have been acquired 
by the pupils, the experience of the students in matters of 
pubHc and personal hygiene, the data of physical training, the 
other health agencies and instrumentahties of the school, and 
the public-health agencies, both governmental and voluntary. 
There is a great deal of health instruction that is collateral 
to other subjects and incidental to school Hfe. Wherever facts 
and principles of hygiene are germane, they should be taught.- 
There need be no fear of wasteful repetition. Repetition 
under varying conditions and with varying associations means 
organized, vital knowledge. The relation ol* air and health 
will serve as an illustration of direct and collateral teaching. 
This topic may be taught in the first-year course in hygiene, 
in chemistry, in biology, in physics, in civics, and in the fourth- 
year course in hygiene. There need be no repetition that will 
cause students to "go stale" on the subject. In the first-year 
hygiene, emphasis will be placed upon the general physiolog- 
ical facts in regard to air and health. This can be scientific 
without laboratory or apparatus. It is only necessary that 
cause and effect be emphasized constantly. For example, 
give as a problem for analysis the results in health and mental 
improvement of the open-air school. The report of the re- 
sults of a year's work in any carefully conducted open-air 
school will provide the data. Then let the students analyze 
the conditions and state the factors contributing to results. 
The work will thus be rescued from the doldrums of grade- 
school repetition and given interest and vitality. It will be 
scientific but will not involve technical knowledge of biology, 
chemistry, or physics. When the student comes to the stud}' 
of chemistry, he will learn the chemical composition of the ai: 
and will have experiments in air-testing. In physics he will 
learn the significance of air currents, of temperature, humid- 



394 EDUCATIONAL HYGIENE 

ity, and perhaps the mechanism of artificial ventilation. In 
biology there should be study of the relation of air to the cells 
of the body and study of the bacteria of the air. In civics 
the relation of pure air to industrial efficiency, and laws and 
ordinances relating to ventilation of schools, factories, etc., 
should be considered. In the systematic work of the fourth 
year there should be co-ordination and integration of the 
knowledge of all the pupils. In few, if any, high schools 
would all the fourth- year pupils have studied all the subjects 
specified above. This would not be entirely a disadvantage, 
as it would give opportunity for co-operative work by mem- 
bers of the class. For example, those who had studied 
chemistry might demonstrate the chemical tests of air. The 
result would be mutual contribution and fuller and more vital 
knowledge.^ 

Such a plan of procedure would integrate health teaching. 
The direct and collateral teaching would not be unrelated and 
unsystematic, but rather would be co-operative factors in 
producing the desired result — ^knowledge that is at once scien- 
tific and practical. 

Content of Instruction. — ^Assuming that formal health in- 
struction is to have place in both the first and the fourth 
years, what should be the content of the courses ?2 Berry 
suggests as the essentials "physiology, bacteriology (which 
is essential to the understanding of the nature of infectious 
disease), personal and social hygiene, sanitation, and phys- 
ical education. . . . Now is the time to emphasize social 
hygiene and sanitation. Let the youth realize that in living 
hygienically he is doing but half his duty; the other half is 
to co-operate with others in the struggle to transform an en- 

* Davis recommends that hygiene be taught in the first year as a phase of 
general science. (Report of the N. Y. School Inquiry, Vol. II.) 

^ If limited to one year, the content need not on that account differ ma- 
terially from that suggested infra. If given in the first year, there would be no 
difference, though in schools where biology is prescribed in the first year the 
hygiene might be included in the biology. If given in the fourth year, the dif- 
ference would be in extent rather than in kind. 



HEALTH TEACHING IN HIGH SCHOOLS 395 

vironment unfavorable to the health of the community. . . . 
There are few pages in modern history more fascinating, and 
few illustrate more strikingly the power of knowledge, than 
those which tell of man's desperate struggle with disease."^ 

Moseley would prescribe a course for all students in anat- 
omy, physiology, and hygiene. The character of the course 
given in the first semester in the Sandusky High School is 
sketched as follows: "The mere learning and reciting of 
lessons from a book may not be useless, but it should be 
supplemented by experiments, some of which the pupils can 
do at home and report on at school. A fresh heart and lungs 
should be obtained from a butcher and the lungs inflated. 
Each pupil should see the circulation in the web of a frog's 
foot or some other animal membrane. Models of the eye and 
several other organs should be examined. The application of 
the lessons to actual living should be discussed freely and the 
difficulties of properly appl3dng the knowledge acquired should 
be overcome if possible. The pupil while in the secondary 
school will not become much of an anatomist or physiologist, 
but should acquire sufficient knowledge of these subjects to 
help materially in understanding hygiene." ^ 

He also emphasizes the conquest of disease. "In a town 
in Africa I interviewed schoolboys, apparently about twelve 
years old, who could tell me about Louis Pasteur. In this 
country are we to turn out high-school graduates who can 
name the wives of Henry VIII but who have never heard of 
Pasteur, or Koch, or Chittenden? Are the adventures of 
iEneas at the court of Dido more important or more interest- 
ing than the discoveries of Reed, Carroll, or Lazear?" An- 
other urges that the high-school course in hygiene be "dif- 
ferentiated to meet the needs of pupils entering specific types 
of vocations." ^ 

nbid.,p. 358. 

2 Moseley, "Some Ways of Teaching Practical Hygiene," School Science 
and Mathematics, vol. 12, no. i, January, 191 2. 
3 Towne, Lillian H., ihid., p. 75. 



39^ EDUCATIONAL HYGIENE 

These citations illustrate the tendency to emphasize 
social and community hygiene in the high-school course. If 
the pupils entering the high school have been taught the 
elements of personal hygiene in the elementary schools, then 
the first-year course in the high school should emphasize the 
social and community phases of the subject.^ The following 
topics certainly should be included: air and health, including 
a study of the ventilation of the school; the public water 
supply, its reason for being and its condition; milk-supply; 
insect carriers of disease; prevention and control of infectious 
diseases, including immunity; vital statistics; ^ food, cooking, 
and pure-food laws; industrial hygiene; the work of the health 
departments, State and national as well as local; and a review 
of personal hygiene with special reference to matters of im- 
mediate significance, such as exercise, military drill,^ recrea- 
tion, sleep, vision, elements of mental hygiene, stimulants and 
drugs, and clothing. Such a content could be given satis- 
factorily in a half-year course of five periods a week; it could 
be given better if integrated with the physical-education work, 
as suggested in the following section, and carried through the 
first year. 

The Drama of Preventive Medicine. — ^Two of the writers 
quoted above. Berry and Moseley, emphasize what might be 
called the drama of preventive medicine. This is well. Here 
is opportunity to appeal to the ancient fighting instinct and 
turn it to account in the conservation, rather than the de- 
struction, of human life. There is the patient heroism of 
research students like Pasteur, Koch, and Chittenden, com- 
parable to the labors of military strategists; there is the mar- 
tyrdom of those like Carroll, Lazear, and Ricketts who have 

* If the work in the grades has been perfunctory, superficial, or desultory, 
then the upper-grade book of any of the series mentioned above would serve 
admirably as the basis of the first-year high-School course. Another useful 
first-year book is Tolman and Guthrie's "Hygiene for the Worker." 

2 Bibb-Hartmann's " The Human Body and Its Enemies " has an admirable 
chapter on this subject, entitled, " Keeping Account of Our Treasure." 

3 In schools that have military drill. 



' HEALTH TEACHING IN HIGH SCHOOLS 397 

sacrificed life on the firing-line of health science, correspond- 
ing to the martial heroes who have held life cheap on many 
a bloody field; and there are the knights errant of medical 
science like Goodhue of Molokai, who serve the outcasts of 
the earth and at the same time add to the knowledge which 
conquers disease.^ 

A large part of the instruction in social and community 
hygiene might radiate from this centre. The teaching easily 
becomes vital, scientific, and dramatic. Let the starting-point 
be biography; let the heroism of the sacrifices and the nobihty 
of the martyrs shine forth; but let the scientific achievement 
in each case be clearly revealed. Concretely, suppose a class 
of thirty pupils. Let the teacher select for study five or six 
of these heroic figures, each representing an important sci- 
entific achievement. Assign each to a group *of five or six 
students, give references, and have reports covering in each 
case: (i) a brief biography, (2) the special episode, (3) the 
scientific achievement. The class exercise will consist of 
presentation and discussion of reports, the teacher correcting, 
clarifying, and vitalizing the process. Science will acquire 
for these students a new dignity, and life a new sanctity. 

Systematic Work in Final Year. — As suggested above, 
the systematic course in the fourth year should unify and 
deepen the knowledge of health matters that may have been 
acquired by the students both in their school studies and 
in their personal experience. This should occupy one semes- 
ter. Two plans are feasible: a rather narrowly defined course 
in physiology based upon laboratory experiment; or a topical 

^ The drama includes privates who are rarely heard of, as well as the laurel- 
crowned leaders. After the death of Doctor Lazear in Cuba two private 
soldiers, John R. Kissinger and John J. Moran, volunteered as subjects of ex- 
periment. Major Reed explained to them the danger of the experiment, the 
inevitable suffering and possible death resulting from the bite of the infected 
mosquitoes; but as they remained firm he then offered them money compen- 
sation. Both declined, saying that they volunteered " in the interest of human- 
ity and the cause of science." "In my opinion," wrote Major Reed afterward, 
"this exhibition of courage has never been surpassed in the army of the United 
States." (Coleman, "The People's Health," p. 144.) 



398 EDUCATIONAL HYGIENE 

course, synthetic in character, utilizing the pupils* knowl- 
edge of the basic sciences, personal experiences, data of phys- 
ical training, and the various health agencies. If the former 
method is followed, a well-equipped laboratory is necessary. 
An adequate text-book and laboratory manual are almost 
equally necessary. ^ If the second method is followed, the 
plan in use in the Sandusky High School is a suggestive 
model.2 The study of hygiene is carried on in connection with 
rhetoricals. "In the first half of the senior year the essays 
all pertain to matters of health and are followed by comments 
by the teacher and sometimes discussion by the pupils." Sub- 
jects: "Various diseases, their effects, their causes, and how 
they may be avoided; the pupil choosing a subject, if pos- 
sible, which he knows about from experience." Other sub- 
jects are: "The most important factors in the maintenance of 
health, the most neglected factors in the maintenance of 
health, erroneous notions about health and disease, length 
of himian life, occupation, exercise, gymnastics, rest, sleep, 
worry, overwork, clothing, bathing, care of the eyes, care of 
the teeth, medical education, a doctor's experiences, trained 
nurses, medical frauds, patent medicines, what a city should 
do for the public health, and quite a list of subjects pertain- 
ing to food and drink." 

The Teacher. — It is essential that the health teaching 
should be "conducted by a teacher who is interested in it and 
will endeavor to make it of practical value. "^ This is logically 
the teacher of physical education. The cultivation of health 
habits and ideals is the chief function of the physical trainer. 
Drills, setting-up exercises, apparatus work, dancing, games, 
athletics, are all worth while but only as they are instrumental 
in building up positive health in the pupils and quickening in 
them a sense of the dignity and the worth of physical fitness. 

* Such as Eddy's "Text-book in General Anatomy and Physiology and 
Experimental Physiology and Anatomy" (American Book Co.) and Hough and 
Sedgwick's "The Human Mechanism" (Ginn & Co.), 

2 Moseley, ibid., p. 3. 3 Moseley, ibid., p. 2, 



HEALTH TEACHING IN HIGH SCHOOLS 399 

The gymnasium and the playground are laboratories for the 
study and the appHcation of the principles of hygiene. "The 
teacher of physical training and gymnastics is the most 
effective because the most intimate teacher of personal hy- 
giene. The physical examination and the conduct of phys- 
ical exercises give occasion and opportunity for instruction in 
every important aspect of hygiene both personal and general. 
The harvest from this field is rich for the high-minded and 
adequately prepared teacher." ^ After all, effective teaching 
is not that which develops a subject but that wtich touches the 
individual. Adequate physical examination, without which 
physical training is shooting at random, brings the teacher 
into the closest and most confidential relations with pupils. 
It enables the teacher not only to prescribe regimen for the 
individual but also to generalize the physical conditions and 
needs of the mass of pupils. It opens the way for effective 
co-operation with parents, without which instruction is largely 
void of practical results. It is rational and economical, 
therefore, to concentrate in the hands of the physical- training 
teacher both the practical training in physical morals and the 
scientific and formal teaching of physiology and hygiene. 

This is in line with the tendency, in the general super- 
vision of health in school systems, to concentrate all health 
activities in one department. The Boston Department of 
School Hygiene, which is the prototype of many others, has 
general control of all matters affecting the physical welfare 
of pupils and teachers, except inspection for contagious dis- 
ease, which is under the Board of Health. The director has 
charge of physical examinations, nurses, instruction in phys- 
iology and hygiene, gymnastics, athletics, and playground in- 
struction. Newmayer^ gives as the functions of "medical 

1 Small, W. S., "Biologic Science and Health," Proceedings First Congress 
of the American Association for the Study and Prevention of Infant Mor- 
tality, p. 34. 

2 "Medical and Sanitary Inspection of Schools, Philadelphia," Lea & Febiger, 
1913. See also Rapeer, "School Health Administration," Teachers' College 
Press, 1913. 



400 EDUCATIONAL HYGIENE 

inspection": detection of contagious diseases, detection of 
physical defects, finding capacity of individual pupil, insuring 
hygienic surroundings, and teaching hygiene and healthful 
Hving. The movement toward the centralization and co- 
ordination of all the health factors in the educational practise 
and environment is very marked. 

The concentration of all the physical-welfare interests of 
college students in the department of physical education is 
already an accomplished fact in most colleges. The activities 
usually so grouped ^'include the teaching of hygiene, gym- 
nastics, and athletics, care of students' health, and, in some 
cases, the supervision of the sanitary conditions of school- 
buildings, dormitories, kitchens, water-supply, and grounds. 
The further development of this growing tendency is limited 
only by the supply of competent men." ^ In the College of 
the City of New York such co-ordination has been very com- 
pletely worked out under the direction of the professor of 
hygiene and physical education.^ 

It might seem that this plan would emphasize personal 
hygiene at the expense of social hygiene, but that is far from 
necessary. Wherever students have community interests and 
practises there will arise problems of community hygiene. 
''The sanitation of the exercising hall, the locker-room, and 
the swimming-pool are emphasized as matters of community 
importance and each student is taught the obhgation to him- 
self and to the community in which he lives in his relation to 
his fellow students. In this connection it may be noted that 
the swimming-pool serves as a sort of index to the standard 
of hygiene maintained by the student community using the 
pool. If the bacteriological analysis shows evidences of hiunan 
contamination, the fact is brought to the attention of the 

^Meylan, "Report of the Committee on Status of Instruction in Hygiene 
in American Educational Institutions," Proceedings Fourth Congress of 
American School Hygiene Association, 1910, p. 173. 

2 Storey, "Protection of Student Health in the College of the City of New 
York," Bulletin No. 46, U. S. Bureau of Education, 1913, "School Hygieae," 
p. 7S. 



HEALTH TEACHING IN HIGH SCHOOLS 401 

classes using the pool and responsibility is placed upon 
them."i 

At present the swimming-pool is exceptional in the high- 
school equipment. Within the next decade it will be common 
in large new high schools. Where it exists, no better means of 
community hygiene instruction could be desired. The co- 
operation of the biological department is required for bac- 
teriological analysis. Where there are shower-baths, students 
are frequently careless about the use of dressing-booths and 
towels. A scarcely less impressive lesson might be based 
upon bacteriological analysis of towels. The active co-opera- 
tion of the student body in promoting cleanliness and general 
community hygiene may be organized. This, indeed, may be 
done independent of any formal teaching of hygiene by 
physical trainer or any other teacher ,2 but W4)uld be a natu- 
ral development of organized hygiene work in the physical- 
training department. 

Physical training should be compulsory through all four 
years. The logical plan would be to have the teachers of 
physical training give the first-year course in physiology and 
hygiene, as specified above, carefully co-ordinated with the 
practical work in physical education. The most vital prob- 
lems of personal and community hygiene should be selected for 
treatment. Time should be allowed for incidental instruction 
in hygiene throughout the course. To insure realization 
in conduct of knowledge acquired in the first year, there must 
be the constant reinforcement of repetition. Application 
and imphcation must be renewed, emphasized, ampHfied. 
It would not be necessary or even desirable to have a fixed 
time for such instruction, but the teacher should be alert for 
occasions for such instruction. Violations of hygienic recti- 
tude by members of the class, illness or quarantine of a mem- 

* Storey, ibid., p. 76. 

2 Hunter, U. S. Bureau of Education, Bulletin No. 48, 1913, "School Hy- 
giene," p. 48. An account of an interesting and successful movement of this 
nature in the DeWitt Clinton High School. 



402 EDUCATIONAL HYGIENE 

ber, revelations of "unfitness" in athletic meets, results of 
physical examinations, improvements made in sanitary con- 
ditions of the school, lunch habits of students, care of lockers, 
ventilation of classrooms — these are illustrations of occasions 
for halting physical exercises and having a heart-to-heart talk 
with {with, not merely to) a class group. Further, there should 
be the means in the gymnasium for demonstrating physio- 
logical and anatomical facts as occasion may arise. A mani- 
kin, models of important organs, charts, and lantern sHdes 
should be essential parts of the equipment of the physical- 
training room. References should be easily available so that 
important topics may be studied further and reported upon. 
Conclusion. — ^Two objections may be made to this plan of 
procedure — one, that as yet comparatively few high schools 
have a teacher of physical training; the other, that com- 
paratively few teachers of physical training possess the scien- 
tific training in biology, physiology, and hygiene requisite for 
the successful conduct of the health teaching as outlined. 
These objections lie not against the plan itself but only against 
its present feasibility. It is true that few schools have a 
teacher of physical training — 8 per cent according to Gulick's 
investigation, cited above — ^but it is equally true that few 
schools include health teaching in their courses of study. 
Recognition of the unitary character of these two factors in 
health education will give both impetus and direction to the 
movement for definite and systematic teaching of the sub- 
ject. The other objection is no more substantial. It is prob- 
ably true that many, if not a majority, of the present high- 
school teachers of physical training are disciples of some 
"school" of gymnastics. Comparatively few have been 
broadly trained in the sciences that are fundamental to the 
understanding of hygiene. They are teachers of gymnastics, 
not of hygiene. This condition, however, is improving. Uni- 
versities, colleges, normal schools, and the special schools of 
physical training are gradually establishing physical educa- 
tion on the right basis. An insistent demand for teachers 



HEALTH TEACHING IN HIGH SCHOOLS 403 

of physical education, adequately trained according to the 
standards indicated in this chapter, will tend to hasten the 
supply. In the meantime, the instant need must be met in 
the practical way suggested at the beginning of this section, 
by placing the health instruction in the hands of a teacher, 
regardless of his major subject, who is interested in the matter 
and will grow up with the work. 



CHAPTER XXII 
INDUSTRIAL HYGIENE AND VOCATIONAL EDUCATION 

The Anomaly. — To those who have studied the pressing 
problems of working people, a serious anomaly appears in 
American industrial education. The movement for industrial 
education has been a most desirable effort to help the great 
masses of our people solve successfully through public educa- 
tion one of the most serious problems of life — that of making 
a living. A rough analysis of this problem has associated 
vocational preparation with forges and lathes, special schools, 
and costly apparatus. Educators have clamored long and 
loudly for appropriations with which to begin this work. 
They have said : We can do nothing until we get the money 
with which to purchase this equipment. And they have 
done nothing without it. 

Now a more thorough survey of the prime needs of the 
world's workers will reveal two very essential and funda- 
mental factors of vocational education which most indus- 
trial courses and schools very largely overlook, and which 
are moreover comparatively inexpensive. These are, first, 
the development of general industrial intelligence, including 
acquaintanceship with the complex industrial world of 
the present; and, secondly, thoroughgoing education in gen- 
eral, industrial, and occupational hygiene. While they are 
waiting for appropriations, school systems could be giving, 
without very great outlays of money, fundamental instruction 
with regard to our complex industrial life, and this invalu- 
able health education largely by the use of the schoolmaster^s 
favorite instrument — the book, a simple, inexpensive tool. 

404 



HYGIENE AND VOCATIONAL EDUCATION 405 

Health Education for Workers as Vocational Education.^ — 
Let us glance at just one of these propositions — that in 
reference to health education for workers as primary voca- 
tional education. What is the health problem for our work- 
ing people? From extensive studies of mortality statistics 
and the data of private and public insurance agencies here 
and abroad, as well as from many special studies, we learn 
with respect to the illness problem that there are in this coun- 
try not less than 13,000,000 cases of sickness each year among 
those engaged in industrial pursuits. The effects of such 
illnesses are well known. Illness reduces bodily efhciency, 
causes losses of work and of wages, and frequently ends in 
death. Webb, Devine, and other social students and workers 
are agreed that to the sickness of workers is directly due 
over 25 per cent of all poverty and destitution. 

Health Conditions of Workers. — Rubinow, in his " Social 
Insurance," reports that in Austria, where the government 
insures workers against illness and where accurate records are 
kept of the illness problem of workers, with nearly three mil- 
lion workers insured in 1907, there occurred 1,623,000 cases 
of sickness, causing a loss of 28,000,000 days. Fifty-three 
per cent of the entire working army suffered such loss, and the 
average time lost was 17 days each. How much of low vital 
working efficiency there resulted could not well be measured. 

In Germany, with over 13,000,000 insured against sick- 
ness, there were (in 1908) 5,200,000 cases of illness, or 40 
per hundred persons, and the number of days lost was 104,- 
000,000, or 20 days for each case of sickness, and an aver- 
age of eight days for each of the thirteen million insured. 
Of course, these are only partial costs, since the public taxa- 
tion for public hospitals and other such health agencies is 
not here included, and still other costs are omitted. 

Since we have as yet in this country no such systems of 
social insurance, we do not yet have accurate statistics of the 
health problem of our own workers. But these illness losses 

iThis chapter appeared in the Educaiiond Review for December, 19 14. 



406 EDUCATIONAL HYGIENE 

may from several sources be computed as an average of over 
two weeks of work and not far from 5 to 15 per cent of the 
workers' annual wages, including medical, burial, and other 
such expenses, both private and public. When we study 
the annual wages of our workers, a large proportion of them 
now being industrial wage-earners of the factory type, and 
find that the median annual wage is not far from $650 to 
$700, and that this sum is hardly up to, and certainly not 
above, the minimum amount necessary for a family with 
which to maintain a minimum standard of living — when we 
see our industrial population working so close to this mini- 
mum — then we realize what the direct and indirect loss of 
even one-twentieth of the annual wages for sickness really 
means, especially when we learn further that about 50 per 
cent of it is reasonably preventable. Our working people 
cannot afford it. 

Yet such data scarcely show up the complete death and 
lowered vital efficiency problems of workers. Over one- 
fifth of the children brought into the world each year, at 
such cost, die in the first year; one-fourth are dead before 
the age of five; and half of all born into the homes of our 
workers die before the age of twenty- three. Over 1,600,000 
of our total population die each year, 100,000 of them of 
school age. This is an annual loss of about 2 per cent of 
our total population, which, in an enlightened civilization, 
is about double what it should be. 

We cannot avoid the conclusion that the most fundamental 
form of general and vocational training is that which would 
enable the working population to meet more effectively these 
death, illness, and lowered vital efficiency losses. More- 
over, the young men and women, the boys and girls of our 
schools, very much need this type of vocational education be- 
cause they themselves are seriously defective and ailing. 
Doctor Chisholm's studies of the girls preparing for work in 
Manchester, England, the great amount of data collected in 
our medical supervision of schools, and the statistics of ex- 



HYGIENE AND VOCATIONAL EDUCATION 407 

aminations for army recruits and for those entering industry 
abroad, all show the extreme importance of complete and 
thoroughgoing systems of educational hygiene for our work- 
ing people. 

Health and the Working Girl.— Mrs. Woolman says of 
the girls entering the Manhattan Trade School for Girls: 
^'The young wage-earner who goes into trade untrained at 
fourteen years of age is greatly handicapped by her physical 
condition. Either through ignorance or neglect, early symp- 
toms of disease are disregarded, and it is not until she finds 
herself out of employment as a result of physical weakness 
that she realizes that good health is the capital of the working 
girl." And again: "The young wage-earner ... is much 
handicapped by her physical condition; heredity, poor habits 
of life, and insanitary homes show their effects on her. The 
girls, however, are young enough to remedy many of their 
defects. In a few months they will be in positions demanding 
eight or more hours a day in which they must strain every 
nerve and bend all their energies to meet the standard brought 
about by trade competition." 

We do not need to demonstrate by the statistical studies 
that have been made that the general, the industrial, and 
the occupational hygiene phases of vocational education 
for health efhciency are wofully neglected in the schools 
of this country. Our teachers do not know the elements 
of general, personal, and public hygiene, not to mention 
industrial and occupational hygiene. We have few good 
text-books in hygiene in use, and little or no time is given 
to the subject as a school study. An extensive study of 
actual courses in vocational education shows that, with but 
practically one exception, the only progressive work of this 
type is being done abroad. Our vocational courses, like our 
general elementary and high-school courses, almost entirely 
overlook this form of vocational preparation. 

The anomaly, then, in summary, is about as follows: 
hygienic education an indispensable phase of vocational 



4o8 EDUCATIONAL HYGIENE 

education; and yet an almost total lack or great inefficiency 
of health education, both general and vocational; millions 
of workers suffering high illness, death, and lowered vitality 
losses; and yet the spectacle of educators clamoring for the 
costly tools for a narrow type of vocational training while 
at the same time neglecting the preparation so near, so 
fundamental, and so comparatively inexpensive. 

What is Being Done. — The best evidences I have been 
able to find of adequate attention to this important matter 
have been in Munich, Germany, some schools of England, 
the schools of Sweden, and the Manhattan Trade School for 
Girls (not true for the one for boys as yet) in New York City. 
Doctor Kerchensteiner in Munich has not only medical ex- 
aminations and follow-up work and attention to sanitation 
and physical education, but he has a regular course intended 
to give intelligence with respect to the complex industrial 
and civic world of to-day and the elements of general, indus- 
trial, and occupational hygiene. His course is called Civics 
and Hygiene. 

Sweden has all these features but adds to them a most 
progressive feature in the form of health vocational guid- 
ance and follow-up work, including annual medical examina- 
tions by government medical examiners until the youth 
reaches the age of eighteen. A young man may be changed 
from occupation to occupation; he may be given shorter 
hours and guidance as to his health regimen; and may even 
be kept out of work altogether until he is physically fit. 
In England, medical supervision and follow-up work with 
some health vocational guidance is rapidly making its way. 
In these coimtries the insurance of workers against sickness 
by the state makes the problem of health preparation perhaps 
not such an acute one as here, yet these countries are leading 
the way in school-health work. 

An American Example. — The Manhattan Trade School 
for Girls gives each girl careful physical examinations, an- 
nually or more often, and supplements this with thorough 



HYGIENE AND VOCATIONAL EDUCATION 409 

follow-up work; the home and school environments are made 
as sanitary as possible; medical, corrective, and recreational 
g3nimastics, including plays and games, are much used, 
meeting individual and class needs; there is a great deal of 
practical teaching of general personal and public hygiene, and 
of the most usable phases of industrial hygiene, developing 
later into specific occupational hygiene for those going into 
definite trades. Last, but quite important, is careful guidance 
and follow-up work along sanitary and personal-health lines 
after the girls have gone into industry. Further than these 
few examples, we can point to little that is worth while. 

Employers Awakening to Health as Capital. — The recent 
success of the Life Extension Institute in getting employers 
of hundreds and thousands of working people to furnish 
each one free of charge with an annual, very % thoroughgoing 
medical examination, and the remarkable revelations of the 
low health status of most of these industrial workers, show 
what the world of industry is beginning to think of thorough 
health education from the earliest years on. It moreover in- 
dicates that we are here on the right track. 

What Must be Done. — Now we have seen the anomaly 
and what is being done in a few places here and abroad to 
eliminate it. Let us next see what in this country must be 
done along this line. Briefly we must have: 

(i) Thoroughgoing medical supervision of all school- 
children, and those before and after the school years so far 
as possible, especially annual or more frequent examinations 
and follow-up work of a corrective and preventive character. 

(2) An improved sanitary environment at home, in school, 
and at work. 

(3) Adequate individual and collective physical education, 
including medical and corrective gymnastics, plays, games, 
recreation, etc. 

(4) Improved teaching of hygiene, general personal and 
pubHc, general industrial, and occupational hygiene, each 
person getting as much of each as is reasonably possible. 



41 EDUCATIONAL HYGIENE 

(5) Careful health vocational guidance up to the age of 
eighteen or twenty if possible. 

School-Health Work. — Elementary and high schools must 
pay more attention to these phases of health education, using 
teachers who have improved health training, and text-books 
superior to those in vogue, along the lines perhaps of the 
Gulick, the O'Shea, and the Ritchie series. In the year or so 
before pupils go out into industry, they must have added to 
their instruction some general industrial hygiene such as is 
desirable for all workers of their kind. And, third, if pos- 
sible, they must have some knowledge of the special hygienic 
precautions necessary in the special occupation the pupils are 
sure to take up, occupational hygiene. Those going into teach- 
ing, for example, must, in their professional training, know 
the hygiene of their occupation, namely, teaching; those going 
into the lead industries must know how to meet the lead- 
poisoning problem; and so on. 

Hygiene Texts for Vocational and Social Preparation. — • 
Fortunately, some good texts are being published which 
will aid in the teaching side of the problem, including gen- 
eral personal and public hygiene, and general industrial 
hygiene. I take time to mention one entitled ^'Hygiene for 
the Worker," by Tolman, a text-book on personal, public, and 
industrial hygiene which hooks on to the keen interest of 
children to go out into industry, and which sets them at 
work in direct industrial preparation in the ways of health 
knowledge, health ideals, and health habits of value to them 
as workers. The chapter headings of this volume may 
indicate the wealth of modern hygienic knowledge recently 
developed which can now be put at the disposal of those 
who wish to help our working people to get fundamental 
preparation for their work. 

These chapter headings are as follows: "Applying for the 
Position," ''Preparing for the Day's Work," "Good Habits 
for the Worker," "Suitable Clothing, Food, and Drink," 
"Alcohol and Tobacco," "The Noon Hour," "Hygiene of the 



HYGIENE AND VOCATIONAL EDUCATION 41I 

Workroom," "Fatigue," *' After Hours," '^Holidays and 
Outings," ''Choice of an Occupation," "Occupational Dan- 
gers," "Accidents," "Poisons and Fumes," "Fire," "First 
Aid to the Injured," "What the Worker Has a Right to Ex- 
pect," "Seasonal Hygiene and Tuberculosis." This is the 
best attempt made so far to meet the need of a text in indus- 
trial hygiene for prospective workers. 

Another new and high-class text for upper grades and 
high school but more general in its appeal and in its subject- 
matter, yet of very great importance, is Coleman's "The 
People's Health." This volume will be a good introduction 
to special industrial hygiene for those who go on into or 
through high schools and trade schools of secondary grade. 
The chapter headings will here again give an idea of the 
wealth of subject-matter available for vital pr^entive medi- 
cine in the way of education in general and industrial hygiene, 
namely: "The Need of Public Hygiene," "Fresh Air and 
the Prevention of Disease," "The Prevention of Disease by 
Pure Water," "Clean Milk and the Prevention of Disease," 
"Pure Food and Pure Food Laws," "Food Values and 
Economy in Food," "The Prevention of Infection," "Human 
Carriers," "Insect Carriers," "Hygiene of Work and Play," 
"Mental Hygiene," "A Sanitary Home," "School Sanita- 
tion," "The Public Health Department," "Health and City 
Life," "Rural Sanitation," "Industrial Hygiene," and "A 
Sound Body Conquers Disease." This volume is even more 
profusely illustrated with remarkably telling illustrations 
than the former. 

Dr. Florence Richards has published also a practical 
"Hygiene for Girls," which is of the new order. 

The Public School and the Public Health.— Here, then, 
we have a tentative programme for helping vocational edu- 
cation to enlarge its service, slightly beyond the giving of 
mere trade skill, to help the workers of the country meet in a 
healthy, vigorous manner these serious problems of life and 
attain genuine social efficiency so long held to be the aim of 



412 EDUCATIONAL HYGIENE 

education. It may seem a somewhat progressive programme, 
but it is not in any sense ultra. As Seager says in his *' Social 
Insurance": ^'In the United States we are still so far from 
considering illness as anything beyond a private misfortune 
against which each individual and each family should protect 
itself as best it may, that Germany's heroic method of attack- 
ing it as a national evil through governmental machinery 
seems to us to belong to another planet." But this feehng 
will soon pass; and the governmental machinery we should 
chiefly use in this democratic country is the machinery of our 
public schools, especially our industrial courses and schools.^ 

1 The State of Wisconsin has recently entered the field of public industrial 
insurance. This will soon show the condition of the working population with 
respect to health and will indicate a needed reform in vocational education. 



CHAPTER XXIII 
SEX HYGIENE AND SEX EDUCATION 

Sex Education. — Sex hygiene is a term that has come into 
popular usage to indicate a phase of education which has 
escaped the attention of educators, owing to the ignorance of 
its importance as well as to the inhibiting force of tradition and 
taboo. In its general significance, it embraces all the themes 
which centre about the sex characteristics of the species. 
It has a special meaning to various teachers according to their 
basic interests. Some educators are carried aw^y by the idea 
that merely teaching the facts of reproduction constitutes sex 
hygiene. Various other teachers and writers regard the facts 
concerning the social evil, the venereal diseases, or eugenics, 
as the main elements of information to be imparted in sex 
hygiene. These conceptions are obviously limited. While 
each constitutes one phase of the sex problem, it by no means 
encompasses the field of sex hygiene. 

From the standpoint of education, the tewa. sex hygiene is 
a misnomer. Sex physiology, sex pedagogy, or sex ethics 
would equally describe the educational content of a course of 
study designed to yield to youthful minds the body of facts 
essential for their wholesome development. The preferable 
and comprehensive term for the field in the mind of educators 
is sex education. This includes the natural training of children 
along normal lines in their duties and responsibihties for the 
development and maintenance of their manhood and woman- 
hood, and involves preparing them for their highest duties as 
the potential parents of future generations. A slight knowl- 
edge of anatomy is essential. Physiology naturally must be 
interpreted in terms of hygiene. All instruction would fail 

413 



414 EDUCATIONAL HYGIENE 

in effective results were it not based upon an intelligent un- 
derstanding of sex psychology and sex ethics. The methods 
of imparting instruction would be blind and chaotic without 
a full appreciation of the methods and values bound up in 
sex pedagogy. Sex knowledge, sex understanding, and sex 
interpretation are equally indispensable. 

Correlation of Sex Education with General Education. — 
Owing to the fact that the importance of sex education has 
suddenly dawned upon the educational world, it has been im- 
mersed in an unusually strong light, and singled out as an 
isolated subject free from correlation with the rest of the 
school curriculum. This unfortunate point of view, arising 
from the concentrated attention now bestowed on the subject, 
loses sight of the fact that sex education is not essentially a 
separate educational problem, but is intricately interwoven 
in the fabric of general education. Assuming that education 
implies the imparting of the facts, processes, and ideals es- 
sential for the development of effective citizenship, it cannot 
be denied that training for parenthood is involved in the gen- 
eral function of education. As courses of study are at pres- 
ent developed, there is a prevailing habit to omit all conscious 
references to the facts pertaining to sex, in so far as they may 
arise in the study and teaching of various subjects now in- 
cluded in the curriculum. It is patent that, to properly 
interpret mythology, a thoughtful mind could receive a wide 
education in facts pertaining to sex that would make no im- 
press upon the youthful minds save as related to mythology. 
The interpretation of the literature of all nations involves a 
close attention to sex evolution, sex facts, and sex content 
that affords abundant opportunity for the gradual and normal 
inculcation of sex idealism. History, music, nature-study, 
sociology, botany, and biology are practically carriers of 
broad lessons in sex education which have largely been neg- 
lected, owing to the fear of polluting the child mind with 
sex facts tending to moral degeneration. ReHgious instruc- 
tion itself, based upon the use of the Bible, cannot be ade- 



SEX HYGIENE AND SEX EDUCATION 415 

quately developed without opening up to the chjld mind 
vistas of thought to be appreciated only in the light of an in- 
telligent understanding of the vocabulary contained in the 
Bible itself. The Bible has not been utilized as its content 
warrants for the giving of sex education. Its use has been 
neglected almost entirely by the religious teachers in whose 
hands for centuries has been the problem of moral education 
of the youth. 

The Problem of the School.— Considerable agitation has 
arisen over the suggestion that sex education be imparted to 
the young. The fundamental opposition has arisen from a 
failure to recognize that sex education is constantly being 
acquired by children. Furthermore, there has been a possible 
lack of understanding that the real problem does not consist 
in determining whether sex education should fee given to chil- 
dren, but under what conditions and by which teachers. 
Ignorance and innocence in childhood, in so far as sex themes 
are concerned, are not one and the same thing. There may 
be chastity with a full knowledge and understanding of the 
facts of life, or there may be gross immorality without any 
true knowledge of the underlying physiology or hygiene of sex 
life. 

The great problem for educators to determine is whether 
they are to assume the responsibility for the normal and health- 
ful instruction of the young with regard to the facts pertain- 
ing to sex, or whether they are to continue to permit childhood 
to gain its information from corrupt and foul sources, from 
erotic literature, or from the evil traditions of the gang. 
Obviously, the teacher cannot shirk his responsibility, while 
education is deemed essential for the betterment of the human 
race. If through the error of centuries sex education has been 
neglected, despite its important educational value, then it is 
incumbent upon the teachers to realize the existent necessity 
for imparting sex instruction and to ascertain the methods 
best calculated to prove effective. 

Sex education merits careful consideration because it is 



4l6 EDUCATIONAL HYGIENE 

an essential feature of the implied educational value of edu- 
cation itself. The taboo which has existed since creation is 
gradually being raised. The traditions involving different 
standards of morality for the two sexes have been the cause 
of great social waste and devastation, and are opposed to 
race progress. The church, the home, and the school have 
uniformly and consciously avoided giving the essential in- 
formation for proper sex conduct, despite the fact that such 
neglect has brought untold suffering to humanity. In the 
inculcation of virtues, stress is placed upon honesty, justice, 
chastity, courage, kindliness, and honor, but in so far as these 
values are to be secured through a conscious appeal to sex 
psychology and sex control, education has been wofully silent 
and indifferent. 

The basis of family life, as a unity for the development of 
society, is founded upon the development, direction, and con- 
trol of the sex instinct. As the basis of love, physical or 
spiritual, the sex instinct demands guidance and development 
in the interests of racial progress. Unfortunately, the ordi- 
nary approach to the subject of sex education has been from 
the pathological side. A recognition of the horrors of the 
social evil, and an appreciation of the relation of the venereal 
diseases to blindness, idiocy, and racial deterioration, have 
served as the starting-point for demanding conscious sex in- 
struction as a palliative measure. From this point of ap- 
proach, it is easy to understand why teachers have feared to 
discuss the subject. The traditional barriers of modesty 
and fear have created a position so difficult that few teachers 
have had the courage to attempt to devise a method for 
dispersing ignorance and giving enlightenment as to the un- 
derlying facts necessarily to be imparted in order to lessen 
these social ravages. 

A few educators, with an understanding of the more seri- 
ous problems involved, have sought to discover the basic facts 
pertaining to sex which should be imparted to children, and 
have sought to devise methods for offering this instruction. 



SEX HYGIENE AND SEX EDUCATION 417 

They have come to realize that a constructive plan of sex ed- 
ucation, pedagogically analyzed, involves a full recognition 
of the part that sex plays in social development and personal 
progress. 

As a result of analysis, sex education no longer can be re- 
garded as a special subject isolated from the rest of life. Sex 
hygiene is bound up in all the subjects of the curriculum. Be- 
cause of the attempts to isolate it from the other subjects in 
the curriculum, it has assumed a monstrous form, astonishing 
and stupefying those seeking only the dangers in the impart- 
ing of sex instruction. If sex education were to be classified 
as a specific carnal subject, it would present most tremen- 
dous difficulties. Constituting a part of general education, 
however, it so sinks its identity in the various subjects now 
taught as to deprive it of the dangers and salacious tendencies 
so greatly feared. Sex instruction should be a-pproached in 
a normal manner, evaluating sex facts in terms of the qhild 
mind. The great obstacle to giving such instruction has 
arisen from the fact that adults rich in experience, saturated 
with tradition, and conscious of sex physiology have failed to 
appreciate the spiritual, ethical, and scientific values of the 
subject as they may be developed in the plastic and undefiled 
minds of children. Pedagogical hesitancy has been founded 
upon a failure to interpret the facts, the processes, and the 
ideals involved in sex education in terms of children's under- 
standing. 

Sex Education According to Stages of Child Development. 
— It is patent that sex education is neither a special subject 
nor one limited essentially to any period of child development. 
Virtually, sex education is a constant process extending from 
infancy to maturity and even until senility. The methods 
devised for instruction in literature, mathematics, history, and 
nature study naturally vary at different periods of the psycho- 
logical development of children. Similarly, the methods em- 
ployed in imparting sex instruction must vary according to 
the age, sex, family environment, nationality, sex precocity, 



4l8 EDUCATIONAL HYGIENE 

and mental development of children. For the purpose of 
convenience in considering educational methods to be em- 
ployed, it has been suggested by a committee of the American 
Federation of Sex Hygiene that the matters and methods of 
sex education should vary according to more or less definite 
age periods, as, for example: one to six years, six to twelve 
years, twelve to sixteen years, and sixteen years and there- 
after. From the standpoint of the psychological develop- 
ment of children, regardless of distinct chronological limita- 
tions, I have suggested that the matter and methods of sex 
education be divided according to three stages of child de- 
velopment, which I have termed the age of mythology, the 
age of chivalry, and the age of civic awakening. 

The age of mythology constitutes that period of child life that is 
particularly keen in imagination. Mentally, the fairy-tale, the ro- 
mance, the animal story, and nature wonders supply the best intel- 
lectual pabulum. 

Gradually the child outgrows the age of mythology and enters 
the age of chivalry. There is no sharp line of demarcation of the two 
periods, nor can any age be given when the transition occurs. The 
age of chivalry really begins as a prepubertal period. For purposes 
of convenience one may regard it as embracing the years from eight 
to fifteen. Each child, however, is a law unto himself, and the spe- 
cific period of his life that represents the age of chivalry can only be 
determined by noting the physical and psychological development of 
the particular child. 

The child's body is beginning to take on new growth, the sexual 
functions are beginning to expand, the emotional side is unfolding at 
a very rapid pace. The actual expression of the sexual development 
may be marked by the intensification of affection for the family. 

The period of civic awakening in turn marks a further develop- 
ment of character. The child in beginning adolescence appreciates 
that he is part of a community. The world of ideas has expanded. 
No longer is the sharp focus on himself. His thoughts are less cen- 
tripetal. There is a realization of the world outside of the home 
and a recognition of the fact that competition is going on in it. 

The awakening is, however, all designed to view the future. The 
understanding of the relation of the individual to the community or 
the state is slowly coming to play a part in the individual's life. How 
wonderful becomes the sense of power on realizing that each individual 



SEX HYGIENE AND SEX EDUCATION 419 

is laden with responsibility for the health, morals, and progress of 
many others ! Not preservation of self for self, but self-preservation 
to protect others, becomes a new incentive. The selfish idea in the 
prevention of disease, physical or moral, takes on an altruistic aspect. 
Self -happiness at last begins to recognize that it includes and depends 
upon the happiness of others. 

Bearing in mind this artificial classification, it is obvious 
that sex education is a complex problem meriting thorough 
investigation with a view to determining the scope of informa- 
tion to be imparted and the methods for its presentation. 

Despite the fact that sex education appears to be an im- 
perative need, I do not beheve that for many years to come 
it will be regarded as a definite subject. Attempts have been 
made to legislate it into the school curriculum, but thus far 
it has been forced into only a few high schoo^, and sufficient 
time has not elapsed to judge of its effect. In view of the 
history of compulsory teaching as related to alcohol and to- 
bacco, it seems inadvisable to suggest that sex education 
should be made the basis of mandatory instruction. It is 
unwise to give to the subject an abnormal position in the 
category of school studies. Dangerous results would surely 
ensue if fanatics, impressed with the importance of this sub- 
ject, should endeavor to compel its instruction in the ele- 
mentary schools previous to a complete understanding of its 
function there. Carefully devised methods must be thor- 
oughly tested out under normal conditions. While sex in- 
struction must be regarded as an essential phase of educational 
development, it must not be viewed as a dominating force in 
education nor as a basic subject of cultural value or of mental 
development. Its highest significance lies within the realm 
of ethics and the development of self-control. 

Who Should Teach It? — Recognizing the practical impor- 
tance of sex education, one immediately faces the question 
as to who should teach it. It requires no special evidence to 
prove that the responsibility for sex education has been 
shifted in turn upon the church, the home, and the schools. 



420 EDUCATIONAL HYGIENE 

In so far as the fundamental facts in sex education are to be 
acquired previous to school age, it is manifest that the re- 
sponsibility for laying this foundation rests upon the home. 
Parents, however, have not been keenly alive to the necessity 
of this preHminary instruction, nor do they feel themselves 
particularly fitted for undertaking the task. Parental timidity 
is largely responsible for the sin of omission. Attempts to 
arouse parents through the medium of the school would un- 
doubtedly awaken their consciences so that they would re- 
spond to the appeal to give the necessary facts along the 
lines suggested by capable teachers. Parents are particularly 
capable of giving natural instruction, once they appreciate 
their opportunities for such instruction in view of their famil- 
iarity with the vocabulary of their children, their companions, 
and their general experiences. 

In the school itself the difficulties of giving sex education 
are multiplied by virtue of the size of classes, the mixture of 
nationalities, the variations in age, and the diversity of sex 
experience. Coupled with these difficulties are the lack of 
training among teachers and their consequent reluctance to 
impart sex instruction. 

The Training of Teachers. — A great problem arises as 
to which teacher should give instruction, particularly view- 
ing sex education as a specific subject. There should be no 
specific teaching of sex education below the seventh grade 
in the elementary schools. The great problem, therefore, is 
to train all grade teachers as to the methods of imparting 
the general sex content of all the subjects in the curriculum 
in a normal and constructive manner without making it ap- 
pear that any imusual topic is being discussed. To achieve 
this end, some training-schools for teachers are engaged in 
developing courses for teachers that will give to them the 
broad vision necessary for understanding the place of sex 
education in the public schools and will acquaint them with 
the facts which should be developed from the general subject- 
matter and the methods of presenting them to the pupils. ; ' 



SEX HYGIENE AND SEX EDUCATION 42 1 

In the higher classes where departmental systems exist, or 
in the high schools where children are at puberty or in adoles- 
cence, there is a more general effort to devise definite lectures 
upon specific sex themes of informational value and moral 
force. Various teachers claim that the best instructors are 
the directors of physical training, or the biologists, or the 
teachers of nature-study, or the school physicians or school 
nurses. When specific instruction is indicated, the greatest 
stress should be placed not so much upon the subject that is 
taught as on the characteristics of the instructor. Tact, sym- 
pathy, understanding, and example are of equal importance 
to the possession of the facts to be imparted. In possession 
of the knowledge to be disseminated, a teacher of Latin, 
history, or mathematics might be preferred as the definite 
instructor of the specific problems related^ to adolescence 
rather than a blunt, unsympathetic, or callous teacher in 
biology, physical training, or medicine. The basis of selection 
of a teacher in sex education should include the personal 
elements entering into teaching ability as well as the recog- 
nition of the general educational power of the teacher. Ob- 
viously, the teacher to whom is to be intrusted the careful 
process of sex education must be possessed of a knowledge of 
the matter to be presented, the methods of presenting it, and 
a broad comprehension of the relation of the subject to human 
effort and efficiency. He must possess judgment to determine 
whether information should be given to individuals or to 
groups and be able to weigh the effects of his instruction. 
Sex education must be achieved without the development 
of sex self-consciousness and without the stimulation of erotic 
ideation. 

Sex Instruction in the High School.— Considering sex in- 
struction as one of the factors in character formation, it is 
obvious that the place of sex education in colleges scarcely 
requires consideration in this chapter. The position of sex 
education in the high school appears to be definitely deter- 
mined. As normal boys and girls have acquired a large 



422 EDUCATIONAL HYGIENE 

measure of their sex lore before puberty, the informational 
character of sex education in the high schools must possess a 
correctional bent. The vast amount of misinformation ac- 
quired from the streets and the gang — pornographic Hterature, 
pathological booklets, and false interpretations of current 
events as described in the press — has made its impress upon 
adolescent minds. A careful pedagogical effort is necessary 
to eradicate or modify the false impressions and to give the 
definite and accurate information that will raise the plane of 
sex information far from its low level. 

With some limitations, sex education in the high school 
possesses a prophylactic value. The young adolescents, con- 
scious of new physical sensations and emotional stimuli, 
require careful guidance so that the interpretation of their 
physical and emotional development may be sanely directed 
toward high ideals. The more mature students in the high 
schools, even in the first year, who perchance have drifted 
with the current and possibly have succumbed to influences 
dangerous to their physical and moral welfare, need to be 
rescued. For them it is essential to secure a broader vision 
of Ufe. The facts pertaining to sex must be placed before 
them in a clean manner to indicate the dignity of manhood and 
womanhood and to give them an understanding of their duties 
and responsibilities in the light of their social obligations. 
The possibility of developing character during adolescence so 
as to lessen the likelihood of immorality demands the careful 
instruction of high-school students in the facts pertaining to 
sex. This is not a difficult matter for a tactful instructor, 
inasmuch as most of the youths have acquired a large share 
of sex information, though in terms of vulgarity and obscenity. 
With the development of the social consciousness at puberty, 
it is possible to mould character on the basis of an appeal to 
family pride and social responsibility. The mere presentation 
of facts relating to anatomy and physiology will not suffice 
to produce the moralizing result to be sought. In the high 
schools it is possible to give a few definite lectures, collating 



SEX HYGIENE AND SEX EDUCATION 423 

the facts previously imparted in a normal way and dealing 
with the definite sex problems surrounding adolescence. 

The ethical lessons involved in sex education assume the 
utmost importance. Considered from the standpoint of bio- 
logical development, physical education, civics, and ethics, the 
high school may afford definite instruction upon the mean- 
ing of puberty and the relation of the sex instinct to personal 
success and physical health. The wider problems of the re- 
lation of chastity to family welfare, eugenics, and racial ad- 
vancement can be discussed without equivocation, provided 
that undue stress is not placed upon the venereal diseases 
and other pathological phases of the subject. To seek to 
inspire fear and to establish character upon this principle is 
poor pedagogy. The attempt must be made constructively 
to create the ideal and desire for clean living and self-control 
on the basis of a positive knowledge of the essential values of 
sex facts. The dangers of sex education in the high schools 
are practically negligible, provided that instruction is placed 
upon a high biological, ethical, and social plane. Its function 
is to further the development of social responsibility rather 
than to elucidate the merely personal phases of sex prob- 
lems. 

Sex Instruction in Elementary Schools. — In elementary 
schools the position of sex education is different. It is desir- 
able to present sex knowledge to children before adolescence 
without drawing attention to the fact that such instruction 
is being given. The essential nature of puberty may be 
appreciated before this physiological epoch is reached. It 
is necessary to consider each school system as a unit in order 
to determine in which grades sex instruction should be given 
and to what extent and in what manner the facts should be 
imparted. The variations in classes due to numbers, differ- 
ences in age, nationality, and sex precocity increase the difh- 
culties of definite sex education even in the upper grades of 
the elementary schools. If, however, sex education is re- 
garded as essential to the welfare of future citizens, it is man- 



424 EDUCATIONAL HYGIENE 

ifestly important that such education should be given to the 
maximum number of children, and, since most pupils never 
reach the high schools, this becomes possible only through in- 
struction in the elementary schools. It is possible to lay the 
foundations of a rational sex education in such a manner 
that elementary-school children will not leave the schools, as at 
present, entirely ignorant of the great importance of the sex 
instinct in the affairs of the world. 

Naturally, in imparting special instruction, particularly 
for those who are about to leave school in order to go to work, 
the sexes must be segregated. Within the sexes, groupings 
should be made not so much on the basis of chronological age 
as of psychological age. The differences in sex precocity 
make it difficult for teachers, save those of the wisest discre- 
tion, to give instruction in such a manner as to preclude the 
augmentation of self-consciousness. 

The barriers of modesty and shame, having arisen in child 
consciousness just before puberty, increase the difficulties of 
sex education at this period of school life unless one recog- 
nizes that directness of speech, frankness, and sympathy are 
essential in order to overcome temporarily these barriers 
without breaking them down. The proper grouping of chil- 
dren, therefore, is imperative. For this purpose the advice of 
all teachers must be secured even though the instruction be 
given by one teacher. Frequently it is advisable to omit 
from the group some children whose morals are believed to 
be impaired in order to give them individual attention that 
their instruction may be gauged according to their experiences 
and needs. 

Individualized sex instruction, while theoretically desir- 
able at times, is practically impossible in a public-school 
system, save in connection with problems of discipline or in 
response to requests from parents for the imparting of such 
individual instruction. The disadvantage of individual in- 
struction as opposed to group instruction is that it may tend 
to accentuate the peculiar qualities of the instruction given, 



SEX HYGIENE AND SEX EDUCATION 425 

whereas the group instruction makes it appear to be a normal 
part of education to be received by all and does not serve to 
build up an overweening false modesty. 

All steps leading to the introduction to sex education must 
be taken slowly in order that public opinion may constantly 
support the movement. The conservative position of the 
puDlic is perfectly natural, particularly in the light of the op- 
position of teachers toward the introduction of this subject. 
Of primal importance is the education of the public as to the 
meaning of sex education, the necessity for its introduction 
into the schools, and the educational methods utilized by 
teachers. Second, it is a vital necessity that teachers be given 
a proper understanding of the purposes of sex education and 
receive training in the matter and methods essential for the 
proper teaching of the subject. Third, training-schools for 
teachers must organize definite courses for the adequate 
training of those who appear to possess special fitness for 
the presentation of the facts relating to sex problems. Such 
courses naturally must be developed on the basis of biology, 
natural sciences, physiology, anatomy, hygiene, zoology, and 
ethics. The greatest need at the present time is the prepara- 
tion of teachers of this subject. It has been urged by some 
that sex instruction by any type of teacher would be prefer- 
able to the present system of educational neglect. While 
there may be some merit in this argument, it loses sight of the 
fact that improper pedagogical methods may do incalculable 
damage by destroying modesty, lessening shame, inspiring 
fear, and stimulating erotic desire. 

Dangers. — The dangers of early instruction in sex facts 
may arise from: 

(i) The Accentuation of Pathology. — ^To focus all atten- 
tion upon the venereal diseases and the resultant personal or 
social damage is to build up a morbid spirit and develop a 
phobia or encourage an obsession leading to various nervous 
phenomena prejudicial to mental balance, physical health, 
and moral stabiHty. The morbid phases of sex should be 



426 EDUCATIONAL HYGIENE 

relegated to the background and introduced as secondary 
phases of sex education. This is possible without any sacri- 
fice of the content of the subject and with distinct advantage 
in its effect upon mind and character. 

(2) The Stimulation of the Sex Instinct. — ^The method of 
imparting instruction should be totally impersonal. Facts 
should be presented in their widest relations without making 
it appear that any particular individual is being considered 
in the discussion. The sex instinct should be presented as a 
normal part of child nature with attributes that lead to the 
development of manliness and womanliness and that stand 
for the higher virtues. The sex instinct should not be referred 
to as a purely physical phenomenon whose main purpose is 
simply reproduction. All references to the physiology of 
sex may be interpreted in terms of social function rather than 
personal function. Scientific terms should be used wherever 
necessary, and all descriptions of processes should be given in 
plain terms similar to those employed in teaching botany 
and zoology. By keeping the discussions on the plane of 
biology and universal facts, the likelihood of stimulating the 
sexual instinct is decreased. 

(3) The Stimulation of a Morbid Imagination. — By unfold- 
ing all the mysteries of life in a syrapathetic and dispassionate 
manner, all the facts pertaining to sex development are re- 
vealed. The imagination must not be appealed to, nor should 
there be any hesitancy on the part of the teacher in the ex- 
position of facts that will permit an appeal to imagination. 
Descriptions, details of processes, expositions, and reasoning 
should be sufficiently complete, direct, and impersonal to allow 
no room for imaginative processes. The present need for 
frank sex instruction is largely due to the fact that the erotic 
imagination of children receives no conscious check but is 
constantly stimulated through their inability to clear up the 
magnified mysteries. 

(4) The Development of Self -Consciousness. — Tactless in- 
struction, with personal reminiscences, or the direct considera- 



SEX HYGIENE AND SEX EDUCATION 427 

tion of personal problems in the group, tends to develop self- 
consciousness. This is an undesirable method and creates 
hostility on the part of children struggling with their own 
emotions and unable to consider the sex facts save in terms 
of their own personality. At times it may create unnecessary 
fears and lessen self-confidence, create a feeling of self-de- 
preciation, and tend to offset the upbuilding value of the in- 
struction imparted. 

(5) The Breaking Down of Sex Barriers. — Among the nor- 
mal protective devices are certain psychological barriers, 
such as modesty and shame. No instruction should be given 
which would tend to undermine the force of these barriers. 
A vast distinction must be made between false modesty and 
false shame and the more substantial psychological attributes. 
To decrease modesty or belittle shame is to destroy valuable 
factors in conserving or upbuilding strong morals. The pres- 
entation of the facts relating to sex phenomena must there- 
fore take into consideration these barriers with a view to 
strengthening them instead of undermining them. 

(6) The Encouragement of Sex Conversations. — Obviously, 
at the present time matters pertaining to sex constitute no 
small part of the general themes of conversation of boys and 
girls at school. By destroying the secret nature of sex 
themes there is a tendency to decrease the importance of such 
topics of conversation. There would probably be less harm 
in conversations dealing with sex matters were they founded 
upon proper information and ideals than under the present 
system of vulgarity, imaginativeness, and secrecy. ; At the 
same time, every conscious effort should be made to decrease 
discussions of sex themes based upon misinformation, ob- 
scenity, indecency, and licentiousness. 

(7) The Creation of Curiosity. — There can be no question 
that curiosity is a normal attribute existing with undue force 
as related to sexual matters. A rational exposition of the 
problems of sex tends to allay curiosity and not to stimulate 
it. The creation of stronger self-control, founded upon basic 



428 EDUCATIONAL HYGIENE 

knowledge, serves to relieve the pressure of curiosity and 
affords a valuable safeguard against its overdevelopment. 
Careful teaching will not create an abnormal interest in the 
subject, but it will simply serve to guide and direct the 
normal and basic interest with an array of facts and reasons 
which enables it to be satisfied far better than under the 
present system where interest is forced by secrecy, gang in- 
fluence, and vicious literature. Eroticism becomes subordi- 
nated to a healthful interest and a conscious appreciation of 
the meaning of sex in relation to life. 

Methods. — The method of instruction in matters pertain- 
ing to sex is practically to impart such knowledge of sex at 
each period of child life as may be valuable and necessary for 
preserving health, developing high planes of thought, and 
controlling conduct. Recognizing the fundamental facts es- 
sential for the health and morality of the community, it seeks 
to build up normal human beings of high ideals and good 
moral character with the fundamental facts enabling them to 
make an intelligent choice as to action. The point of departure 
in instruction must be the normality of sex life and the nor- 
mality of the sex instinct. The problems of pathology are 
of secondary importance. Anatomy should be^dwelt upon 
as little as possible and embryology should be involved only 
in so far as may be necessary for the interpretation of the re- 
productive phenomena in all the plant and animal kingdom. 
The scientific processes are to be found in the biological in- 
terpretation of nature-study, supplemented by the values to 
be gotten from physical education, civics, hygiene, history, 
and ethics. 

In methods of instruction there is a positive phase which 
has to do with the development of the child and a negative 
phase which deals with the child's environment. It is ob- 
viously impossible for a school to control a child's environ- 
ment, nor is it within the bounds of possibility to safeguard 
children from all contacts with demoralizing and corrupting 
influences in their environment. Instruction as to the im- 



SEX HYGIENE AND SEX EDUCATION 429 

portance of bathing, correct methods of clothing, the values 
of physical exercises, athletics, and recreations of a whole- 
some character, is within the limits of sex instruction in so 
far as it is related to environment. Guidance as to theatres, 
gambling, alcoholism, debasing associates in the gang, the 
advantages of playgrounds, parks, libraries, the importance 
of religion, the necessity of cherishing home life and maintain- 
ing confidences with parents, properly may be included in a 
constructive programme of sex education involving the en- 
vironment of children. 

In the positive education of the child, character formation 
is the ultimate aim. In the study of reproduction during 
the adolescent period, utilizing the facts to be gleaned from 
biology, the ethical implications require greatest emphasis. 
The evolution of human love, the relations of iparenthood to 
family welfare, and the nature and importance of the home, 
together with the ethical relations which should exist between 
parents and children, are ethical and biological concepts of 
exceedingly great value in making appeals to adolescents. 

Gradual Development. — The entire subject-matter of sex 
education must be developed gradually. The subject must 
be evolved. The spontaneous exposition of the great truths 
must not be permitted. Sex education must cover a long 
period of years and one step should be based upon pre- 
vious educational supports. The study of reproduction in 
plants and animals covers a period of years in teaching and, 
when based upon familiar plants and animals, affords abun- 
dant facts for indicating the analogies in human life. The 
purposes of sex education are not merely to be informational 
in character but to yield sufficient material for character 
training. Mere facts in themselves present few motives 
for conduct. The trend of sex education must therefore be 
in the direction of creating definite high motives of altruistic 
character. Obviously, the form of instruction given in night- 
schools to adults may consist of a broader treatment of the 
human aspects of sex problems. Among the adolescents, 



430 EDUCATIONAL HYGIENE 

however, the inspiration of high ideals of sex conduct must 
form the end and aim of the instruction. 

Judgment, tact, sympathy, and understanding are req- 
uisite in order properly to balance the biological facts with 
the ethical concepts so that instruction may not appear to be 
preachment, and so that the basic facts may be presented be- 
fore the essential temptations of youth have begun to assail 
the child mind. 

The use of charts and illustrations merits careful con- 
sideration in order that they may not present more material 
than the child can assimilate in connection with the particular 
subject under discussion. The use of books relating to sex 
education by the children is to be deprecated until adoles- 
cence is well advanced. The value of sex education is en- 
hanced through giving adequate information without creating 
an inordinate interest or awakening an abnormal curiosity as 
to numerous questions, such as would naturally be developed 
through the employment of books which cannot be adapted 
in scope or method of presentation to fit large groups of chil- 
dren in the preadolescent stage. 

Without going into details as to the great number and 
variety of facts to be imparted, I may repeat that the con- 
notations of Hterature, history, and civics must be combined 
with the facts of biology, nature-study, and hygiene and in- 
terpreted in terms of ethics and sociology. During the early 
ages, sex facts must be intellectualized in order not to empha- 
size the developing emotional phases of child nature. During 
puberty, when emotional waves are fast rushing upon the 
child mind, they must be harnessed and directed into channels 
that will do the most good and least damage. The physical 
phases of sex problems should not be stressed for adolescents 
except in so far as they are spiritualized. The intellectual 
appreciation of the facts presented merely furnishes the basis 
of educating the emotions. The normal development of sex 
themes proceeds in three stages: first, the intellectual ac- 
quisition of facts; second, the interpretation of emotional life; 



SEX HYGIENE AND SEX EDUCATION 431 

third, the spirituaKzing of sex consciousness. These three 
stages are not totally dissociated at any period of cliild devel- 
opment but must be most closely interwoven in the instruc- 
tion during adolescence and thereafter. 

Education of Parents and Public Opinion. — ^There are 
frequently times during elementary-school periods when spe- 
cial problems arise requiring specific instruction to be given 
to individual children. This must be done frankly and hon- 
estly, whether it deals with masturbation or gross immo- 
rality. The frank discussion of topics involved in school 
discipline carries with it the obligation to discuss them also 
with parents in order to secure the most effective results. 
While parents represent the persons upon whom rests the 
responsibility for sex education, the school cannot ignore the 
fact that parents are ignorant of the best met^iods of peda- 
gogical procedure. For this reason it is highly desirable that 
schools, through the medium of mothers' clubs, parents' as- 
sociations, or general public lectures, should afford an oppor- 
tunity to parents to receive instruction upon the necessities 
of sex education, together with pedagogical methods and the 
material required at different ages of child development. 
Particular advantage accrues from giving the instruction to 
mothers in connection with the clubs of kindergarten mothers 
during the first year of the child's attendance at school. 
Herein is a wide field of usefulness of the elementary school, 
bringing the school and home in closer co-operation and 
harmony in the interests of sex education of the young. 

In the broad problem of developing a rational public 
opinion that will countenance the freer discussion of the 
serious hygienic and moral dangers involved in the present 
attitude of indifference or neglect, the school has 3. tremen- 
dous responsibihty. Under school auspices parents niay be 
educated to higher ideals and to a more healthful apprecia- 
tion of the importance of conveying to the young a knowledge 
of the sacredness of human development. The school can 
indicate the sociological -importance of sex morality. In ad- 



432 EDUCATIONAL HYGIENE 

dition to this, the school will foster a broader concept as to 
the ethical import of sex education and its relation to the 
welfare of future generations. This may all be given con- 
structively without emphasizing pathology. 

The Need for Trained Teachers. — ^The cr3dng need of the 
present time is the training of capable teachers in this hne 
of educational endeavor. Training-schools must adjust their 
courses to the future needs of the community. The process 
of introducing sex education into the public-school system 
should proceed slowly and advance no more rapidly than the 
education of teachers. This does not mean the creation of a 
new set of specialists in sex themes. It involves merely im- 
parting an accurate knowledge of the essential biologic facts, 
together with the inculcation of tact, understanding, and skill 
in presenting the facts in a sympathetic manner that will 
make an impress upon the minds of children in the course of 
ordinary instruction. For the presentation of specific themes 
in sex instruction broad vision is essential, with a clear un- 
derstanding of the psychology of sex, together with the varia- 
tions in child psychology according to the degree of physical, 
mental, and moral development. 

Conclusion. — ^Thus it is patent that the educational aims 
of sex instruction are to supply adequate information to serve 
as the basis of conscious reasoning with a view to stimulating 
the will to more effective self-control. Modesty, chastity, 
courage, pride, honor, and self-control are normal ends. 
One seeks to subordinate self-assertion in individualism by 
the development of social responsibility and a willingness to 
submit to self-discipline. The function of sex education is to 
preserve health, develop right thinking, and control conduct. 
Its educational values are biological, physiological, psycho- 
logical, hygienic, and pedagogical. Sex education should de- 
termine the evolution of sex character on the basis of the di- 
rection and control of sex characteristics. 



CHAPTER XXIV 
PLAY AND RECREATION AT THE RURAL SCHOOL 

Country Life and Physical Education. — There are three 
general methods of physical education — work, play, and gym- 
nastics. In the city, physical education is mostly through 
play and gymnastics; in the country, through work and play. 
It is impossible in these days of swarming germs for any one 
always to dodge them, to run away from them, or to hide 
from their presence. We cannot filter all the air or sterilize 
all the water or disinfect everything we touch. It is of the 
greatest importance that we should develop •positive vital 
resistance or in some way prepare the body to fight the germs 
it cannot avoid. But far more important than the avoid- 
ance of disease is the developing of that positive side to health, 
which on the emotional side means joy and vivacity, on the 
intellectual side means sanity and optimism, on the physical 
side means sprightliness and the joy of living: the sort of 
thing that children so often express in their hippity-hop as 
they go down the street. It is essentially the spirit of play 
vitalizing the personality. 

In the building up of the positive side of health, the coun- 
try has certain advantages: pure air, plenty of physical 
activity, fairly good water, and an abundance of food. On 
the other hand, none of these things are at their best at the 
rural school. Probably the majority of rural schools have no 
very satisfactory method of ventilation; there is much dust 
from the floors and blackboards; the air is seldom humidified; 
the water supply is seldom satisfactory; and the lunch is 
nearly always cold. If school hygiene is to be on the same 
basis as other school subjects, however, it must not be for the 
school alone but it must establish habits and enthusiasms that 

433 



434 EDUCATIONAL HYGIENE 

will maintain the health in years to come. It is believed that 
all habits of play in the open air tend to do this. 

The Work Fallacy. — It has been generally held in the 
past that country children did not need physical training 
because they got the necessary physical development from 
the work of the farm, but it must be remembered that the 
work of the farm has been almost completely transformed in 
the last half-century. From being a day laborer the farmer 
has become a mechanic and a scientist. He has no more forests 
to clear. He is ceasing to hold the handles of his plough 
about stumps and stones. Ploughs, cultivators, rakes, mowers, 
and reapers have all become vehicles to carry him about his 
farm. Driving a team is usually not strenuous exercise. So 
far as the boy works with his hands, it is apt to be hoeing 
in the garden or pulling weeds. Such work frequently tends 
to cramp the chest and to bring the shoulders forward. While 
farm implements have seats, the seats usually have no backs, 
and the farmer is apt to sit collapsed. There is very little 
work on the modern farm, with all its machinery, that can 
develop the heart and lungs, as did the chopping and mowing 
and cradling and pitching of hay and wheat of pioneer days. 
Physical strength is becoming relatively less important on the 
farms as elsewhere, while vital strength, which consists es- 
sentially of the strength of the heart, lungs, sex, nerves, and 
digestion, is no less important now than formerly. Coimtry 
boys and girls are apt to be roimd-shouldered and flat-chested, 
with forward-slanting heads. Boys who have done much hard 
work are usually awkward and clumsy, almost without that 
grace and suppleness that are characteristic of a child who has 
been trained through play. Country children generally have 
more stable nerves than city children. Their digestion is 
commonly good. But they are apt to be deficient in lung 
capacity and heart development. 

Play at the Country School. — So far as the rural school 
promotes physical education, it is almost entirely through 
play and athletics. There are practically no gymnastics in 



PLAY AND RECREATION AT THE RURAL SCHOOL 435 

country schools in America, though they take a considerable 
time in the scheme of the rural schools of Germany and Den- 
mark. Play is more needed at the rural school than at the 
city school. Throughout the country the farms are getting 
larger. The families are small and are growing smaller from 
decade to decade. It is becoming increasingly difficult for 
the coimtry child to play anywhere except at school. He 
can practically never play team games anywhere else, or 
other games that take a considerable number of players. The 
farmer is apt to say his boy does not need to play baseball 
because he gets plenty of exercise at home, but play is needed 
at least as much for mental health as for physical health in 
the country. Play must give grace and suppleness, strength 
of heart and lungs, correct physical defects, give resistance 
against disease, establish hygienic habits, ancl create the joy 
of life. It is more needed at the coimtry school than else- 
where, because it is almost the only chance the country boy 
has to play, and because the rural school must introduce the 
spirit of play into rural life, which. has grown so serious and 
hard that it is driving the boys and girls, and even the farmers 
themselves, from the farms. ^ 

Larger Grounds for the Rural School. — If the rural school 
is to deal effectively with its problem, the first requirement 
is a larger ground, and a ground that is suitable for play. 
Institute work and lecturing take me into nearly every State 
in the Union and ever3n;vhere I find nearly the same con- 
ditions. Usually the yard is not more than half an acre in 
area. It is often evident that it must have been selected for a 
playground because it was good for nothing else. Very seldom 
indeed is there any attempt to make it attractive with fences 
or vines or trees. In less than one per cent of the grounds is 
there any play equipment. Great interest is manifested in 
educational circles just now in the improvement of the rural 
school, and it may fairly be said in a large way to occupy the 
centre of the educational stage. While the percentage of 

* See Curtis, "Play and Recreation for the Open Coimtry " (Ginn). 



436 EDUCATIONAL HYGIENE 

country children to city children is decreasing from year to 
year and faster than the percentage of rural adults to city 
adults, the majority of the children are still educated in rural 
schools. There are probably at present only about one 
hundred and fifty counties in this country where there is any 
systematic attempt to organize play for country children. An 
appreciation of the need is becoming general, however, and 
we may expect great improvement in the near future. State 
departments are now often recommending that rural schools 
get two or three acres as a minimum area for school 
sites, and in some States they are practically compelling 
playgrounds of such size, by refusing otherwise to approve 
of the plans. The State of North Dakota by law now re- 
quires two acres as the minimum for rural schools. This 
demand for a larger ground springs from a desire for a larger 
use, so there is every reason to expect that there will be more 
play and better play at the rural school in the future than 
there has been in the near past, at least. 

The Consolidated Rural School. — All rural educational 
progress is moving in the direction of the consolidated school. 
With the depletion of rural population and smaller families 
many of the once populous one-room schools now have only 
five to ten pupils. It is expensive to hire a teacher lor these 
few. Everywhere agriculture and domestic science are com- 
ing in, and it is almost impossible to teach these at the one- 
room school. But to my mind the most weighty reason of 
all for consolidation is a social one. Country children are 
diffident and backward on account of a lack of acquaintance- 
ship. More than any other child the country child needs to 
go to a large school. The school offers the only opportunity 
that country children have to play team games, and of ttimes 
there are not enough children at the one-room school to play. 
The boy in America who has never learned to play baseball 
is quite as much handicapped as the boy who has never 
learned arithmetic. The great handicap of the country is its 
isolation, and the natural cure of that isolation is a social 



PLAY AND RECREATION AT THE RURAL SCHOOL 437 

centre where the people can come together. Probably the 
consolidated school is the best social centre that a rural com- 
munity can have. There are several States that now give 
special State aid to consolidated schools, and the movement 
is well advanced in many States. 

At the consolidated school there is usually a good-sized 
playground. The average area is probably not less than 
four acres, as the grounds are often ten to twenty acres in 
size. In some cases there is an attempt to have a township 
picnic-grove and ball-field at these grounds also. On these 
grounds there is opportunity both for the play of the school- 
children and of the young men of the community as well. 
The consolidated school makes possible most of the things 
that are essential to the welfare of the rural community.* 

Better Games. — If play is really to meet tHfe need of phys- 
ical and social training in the coimtry, there must be better 
games. We usually think of baseball as the one game for 
boys, but baseball is not adapted to the one-room schools of 
the country, because it requires more ground and more older 
boys than there are at these schools. Probably less than one 
per cent of them have eighteen boys who are old enough to 
play baseball. Baseball at best has a narrow age range, 
from about twelve to twenty-five. It does not meet the need 
of the girls at all, and the girls need the play far more than 
the boys do because they get so much less open air and play 
than the boys at best. Indoor hasehall, with its smaller 
diamond, fewer players, and large soft ball, is a much better 
school game than baseball, because it does not require so much 
room and because it has a far wider age range, as it may be 
played by any one from eight to sixty. It has a far wider 
time range, as it is played in the fall as well as the spring, 
and in the late fall and early spring when the sting of a hard 
baseball would be insufferable. It is played by the girls 
nearly as much as the boys, and, as it has a very much smaller 

1 See Monahan's bulletin on consolidation by the U. S. Bureau of Edu- 
cation. 



438 EDUCATIONAL HYGIENE 

field, it can be played very comfortably with five players on 
a side. Indoor baseball is played mostly out of doors at 
present, on a thirty-five-foot diamond. 

Probably the best game there is for the rural school is 
volley-ball, a game played with a large inflated ball over 
a tennis-net or rope. This game has several very great 
advantages. Most country children are stooped and round- 
shouldered; volley-ball requires the player to keep his head 
and shoulders back and is a natural corrective of these 
bad positions. Volley-ball is played by the girls as much as 
the boys, and, as was said before, the girls are the great 
problem. Country girls seldom learn how to play any ath- 
letic games, as the tradition is that vigorous play is unlady- 
like. Girls at fourteen have only thre^-quarters the lung 
capacity of boys of the same age. Blood tests always show 
their blood to be in poorer condition on the average. The 
German figures, given by Schmidt, indicate that tubercidosis 
is about 25 per cent more prevalent among girls than boys 
in Germany. Volley-ball can be played fairly well with two 
players on a side and even the one-room school will usually 
have at least four children who are eight years old or older. 
Volley-ball has the widest age range of any of our games 
except golf, as it can be played very comfortably until the 
player is seventy. It thus not merely meets the needs of the 
school years but of later Hfe as well. 

There should be croquet at the country school, because 
croquet is a good country game and the school must intro- 
duce it into the community. 

Tennis is another game that is in every way suited to the 
country school and the country community, and it should be 
played at the school, if there are older scholars, for the same 
reason that croquet should be, in order to introduce into coun- 
try life and custom a game that is suited to the children and 
adults alike. Tennis is the country game of England. It 
takes too much land for the city, but is in every way suited 
to rural conditions. 



PLAY AND RECREATION AT THE RURAL SCHOOL 439 

If the school is very small indeed, say three or four pupils, 
tether-hall is probably the best game of all. Of course, there 
are many games of lower organization, such as prisoner's base 
and pull-away, that the children should also play. 

In introducing games, only one new game should be started 
at a time, and this should be played until the children have 
become skilful and begin to tire of it before another game 
should be started. There should always be an attempt to 
secure permanent teams and to keep the score from day to 
day. Scrub teams never get anywhere. They do not secure 
practise or inspire loyalty. In order to get any new game 
started it is almost necessary for the teacher to play with the 
children continuously until some little skill is acquired. There 
are four sizes of the indoor baseball. If the ground is of good 
size, the fourteen-inch ball is usually preferred by the chil- 
dren. But in small grounds, especially where the children 
wish to play long ball also, as they usually do, the seventeen- 
inch ball is best. In prairie countries, where high winds are 
common, the seventeen-inch baseball is more serviceable as a 
volley-ball than the regular ball. It can also be used very 
satisfactorily in playing dodge-ball and a number of other 
games. The rules for volley-ball and indoor baseball can be 
secured of any athletic supply house. For general games 
consult " Games for the Playground, Home, School, and Gym- 
nasium," by Jessie Bancroft; '' Education by Plays and 
Games," by George Johnson; and "The Teaching of Play," 
by W. P. Bowen. 

Play Equipment. — School people are apt to think that the 
introduction of play into the school means the erecting of 
swings, giant strides, see-saws, etc. In matter of fact, such 
equipment is of minor importance and may be omitted al- 
together without seriously handicapping the work. In the 
organization of play, the first thing to do is to furnish the 
equipment for the games. A baseball is essentially communal 
property. All the members of the two teams that play with 
it use it alike. A boy cannot be expected to furnish base- 



440 EDUCATIONAL HYGIENE 

balls to the school, and of course the same is true of bats, 
volley-balls, and many other similar pieces of apparatus. 
If the school wishes to encourage baseball or volley-ball, it 
must furnish the balls and other equipment. This is by far 
the most important apparatus for any playground. Of course, 
the pupils may co-operate to purchase such equipment or 
other means may be invented for raising the necessary money. 

Second in importance comes the equipment for such 
athletics as are suited to the rural school. There should be 
a horizontal bar with sand underneath, where the boys can 
chin and do stunts. All boys like to perform on a horizontal 
bar, but if it is over the hard ground there are likely to be 
serious accidents. There should always be a jumping-pit 
filled with sand and with a take-off board set plumb with the 
ground. Children between eight and twelve are probably 
more fond of running and jumping than they will ever be 
again. It is well to have the distances marked in feet and 
half feet on the side of the pit. There should be the stand- 
ards for the high jump as well, as the children are rather more 
fond of the high jump than they are of the broad jump. Some- 
where at the side of the ground or along the road, if it is 
level and in good condition, a sixty and one-himdred yard dash 
should be marked off. Children all deHght in these contests. 
A stop-watch adds very greatly to the interest in running, but 
children love to run against each other even if they do not 
know their time. A race that is more than a hundred yards is 
seldom wise at the district school. 

For various reasons, the swings and see-saws cannot make 
the same bid for school support that the equipment that I 
have mentioned can. A baseball is meaningless as individ- 
ual property. A boy cannot play baseball alone. A swing is 
usually individual property, as only one or two children can 
swing at a time. The swing causes many quarrels and acci- 
dents. It is relatively expensive, and hard to take care of. 
It gives no social training and little physical training. The 
country child is with companions all too little. While he 



PLAY AND RECREATION AT THE RURAL SCHOOL 44 1 

is with them he should play social games that he cannot play 
at home. The swing and the see-saw belong properly at home 
and not at school. The only reason why it would be worth 
while to install them at the school at all is in order that the 
parents may be encouraged to put them into the dooryard. 
It is probably well to have a sand-bin for the little children, 
though this also belongs rather to the home than the school. 

If the school directors are not willing to furnish the equip- 
ment that is needed, the school itself can usually do it by hold- 
ing an entertainment. This entertainment will probably be 
also a valuable social occasion to the country, will make the 
teacher acquainted with the parents, and will be a real edu- 
cation for the children in social service. Forty-seven such 
entertainments were held in Winnebago County, Ilhnois, last 
year, which yielded on an average a little mo^e than thirty- 
five dollars apiece. This is ample for the play needs of a 
rural school for a year or more. 

The Standard Athletic Test. — ^The standard athletic test 
was designed by Doctor Gulick while he was director of phys- 
ical training in New York City. It is practically a pass mark 
in physical training. By the time a boy is thirteen years of 
age we expect him to be in the seventh grade. The test says 
that by this time he should be able to chin a bar four times, 
jump five feet nine inches standing, and run a sixty-yard dash 
in eight and three-fifths seconds. We all tend to come up to 
standards if we only know what they are and what is ex- 
pected of us. The test should be carried on to the adults. 
This test was tried out in Ulster County, N. Y., upon the 
country children. The farmers thought in the beginning 
that anything that city boys could do would be '*pie" for 
sturdy country boys, but were surprised to find that scarcely 
a boy could pass the test. This set the boys to practising all 
over the county, with the result that many were able to pass 
before the year was over. In some places it is customary to 
let the boys try out in one event at a time, taking possibly 
first the chinning, then the jumping, and finally the running. 



442 EDUCATIONAL HYGIENE 

In other places they require them to practise all the events 
together and do the three stunts at one test. 

The new standards and rules may be had from the hand- 
book of the Public School Athletic League issued by Spalding, 
or from the Playground and Recreation Association of America 
at No. I Madison Avenue, New York. The new test is a 
graded test as follows: 

First Test 

Pull-up (chinning) 4 times. 

Standing broad jump S feet 9 inches. 

60-yards dash 8% seconds.^ 

Second Test • 

Pull-up (chinning) 6 times. 

Standing broad jump 6 feet 6 inches. 

60-yards dash 8 seconds. 

Or loo-yards dash 14 seconds. 

Third Test 

Pull-up (chinning) 9 times. 

Running high jump 4 feet 4 inches. 

220-yards run 28 seconds. 

The following general rules shall govern the final com- 
petition: 

No boy is permitted to receive more than one badge for any grade 
in any one year. 

It is necessary to qualify in all three events in any one class in 
order to win a badge. 

There shall be but one trial in chinning, one in the dashes, and three 
in the jumps. 

Beautiful bronze badges have been designed by Professor 
R. Tait McKenzie, of the University of Pennsylvania, for 
the winners of these three tests. These are furnished by the 
Playground and Recreation Association for fifteen cents each. 

Interschool Contests. — The best place there is for inter- 
school contests is at the rural school. In our great city high 



PLAY AND RECREATION AT THE RURAL SCHOOL 443 

schools we have the spectacle of eleven sturdy young giants 
on the gridiron getting much more exercise than they need, 
while all the weaker ones, to whom football might have been 
a life-saver, sit on the grandstand and shout. If the rural 
school is to hold contests with other schools, it must use all 
its available material on its ball teams, and it must train its 
weaker members in order to win. In the various contests 
that may well be held at the same time, nearly every child 
should compete in something. These contests are a great 
aid in developing enthusiasm and getting the children to 
practise. They are essential to the larger education of the 
country child, because the country children have no sports- 
manship. They do not know what it is. They cheer their 
opponents' mistakes, try to annoy them in their play, call 
them names, dispute decisions, and the like. iThey do these 
things because they do not understand that these things are 
unsportsmanlike. Sportsmanship is essentially primitive eth- 
ics of the sort to which the boy is most subject and he can- 
not afford to miss the training. 

Country children are diffident and backward on account 
of the lack of experience and acquaintanceship. Almost any- 
thing that takes them out of their own neighborhood to meet 
other children and compete with them will be valuable. 

The rural school has no loyalty. The easiest way to de- 
velop it is always through contests with another school. 

Play Festivals. — ^A considerable number of counties in sev- 
eral States are now holding play festivals every year. This 
is apt to be a large event and arouse much enthusiasm. It is 
one of the most hopeful means of setting the whole country- 
side to playing. The long races are to be avoided, and if 
basket-ball is played it should be for short halves. The first 
rural play festival in this country, so far as I know, was organ- 
ized by President Scudder, of the New Paltz Normal School, 
in 1905. There are a number of normal schools that are now 
holding each year similar play festivals for the children of the 
counties in which they are placed. There are now some ninety 



444 EDUCATIONAL HYGIENE 

or more county secretaries of the Young Men's Christian As- 
sociation, nearly all of whom are organizing athletics over at 
least a part of the county in which they are placed. There 
are probably a himdred or more county superintendents of 
schools that are organizing athletics and play festivals in their 
counties. There are no statistics, but in most large gather- 
ings of teachers in whatever State they are held I meet one 
or more such superintendents. Probably the most salutary 
thing that could happen to the rural community would be 
to give the county superintendent an assistant who might 
organize the recreational facilities of the school and the com- 
munity; or, in the face of the present social imrest in the 
country, perhaps it would be better to give the supervisor of 
recreation an assistant who should be superintendent of 
schools. The State and local supervisors of hygiene as sug- 
gested in former chapters will meet the need in an ideal way. 

Perhaps the largest and most successful rural-play festival 
that is being held is the one that is organized by a special 
committee at Amenia, N. Y. 

The School Excursion. — The school excursion is little 
known here, but it is very common abroad. In Germany 
these trips not infrequently cover a hundred miles or more, 
and last for a week or even three or four weeks, during the 
summer at times. The children walk from place to place 
and cook their meals by the wayside. They sleep in the barns, 
on the floors of inns, in the barracks of the soldiers, or in 
special schoolrooms transformed into dormitories for the 
purpose during the summer. They have a good time, hold 
athletic contests with children in other villages, and come to 
know the country and the people at first hand. They become 
so fond of these walking trips that they continue to walk for 
the rest of their lives. 

It is essential that we should introduce these excursions 
into our schools, for various reasons. Walking is good exercise, 
and, if an enthusiasm for it is once acquired, it is likely to be 
continued during the remainder of the life. One of the serious 



PLAY AND RECREATION AT THE RURAL SCHOOL 445 

deficiencies of country life is that country people have never 
learned to love the country or to observe the nature world 
around them. As the German children are on the way the 
teacher points out to them the distant landscape, the beauti- 
ful sunset, or mountain view. They come to know and love 
the common birds and flowers. I am persuaded from my own 
experience that children will learn far more that they will 
remember on such trips than they will in any similar amount 
of time in school. Isolation is usually held to be the greatest 
drawback of the country, and walking, especially for girls 
and women, who often do not have a horse at command, is 
the most fundamental of all ways of overcoming isolation. 

I should like to see Friday afternoons during the pleasant 
weather of the year devoted to these trips, and occasionally 
there should be a week-end camp of the girls wi^h their woman 
teacher, or of the boys with their man teacher. There is no 
other similar opportunity to get a personal hold over children. 

The Boy Scouts. — The Boy Scouts is a very recent order. 
Begun not more than ten years ago, it has already encircled 
the world and is found in every civilized country. The Boy 
Scouts of America was organized in January, 1910. But 
there are now more than three hundred thousand Scouts under 
some seven thousand Scout Masters in this country. The 
order is seeking to train into boys the hardihood and re- 
sourcefulness of the pioneer, to give a love of nature, and the 
arts of the woods and fields. It encourages walking and 
camping, athletics, chivalry, and courage. 

Scouting appeals to the love of adventure and activity, 
which are fundamental to boy nature. The Scouts are offer- 
ing to boys what they have always loved to read about and 
longed to do. The Scouts are now organized in nearly every 
small village in the United States, but the order has scarcely 
touched the country. Under existing circumstances the rural 
village is undoubtedly the best place for the organization of 
the order. It is not far from the village into the open country 
for walks and scouting. There is apt to be in the village some 



44^ EDUCATIONAL HYGIENE 

one who may be Scout Master. The boys have plenty of 
time and they need the training. The boys on the farm do 
not need the order so much. They are in contact with nature 
already. They are getting some of the Scout experiences 
directly, and are learning to do some helpful kinds of work. 
But the great difficulty in the way of the organization of the 
Scouts in the country is the impossibility of securing Scout 
Masters. Scout Masters are not paid, and the country has 
not yet developed the spirit of social service. There are very 
few farmers who would feel like undertaking it even if they 
were paid. The only possibility of a general organization of 
the Scouts in the country seems to be to put them into the 
curriculum of the consolidated school. There they would be 
possible, and I believe well worth while. 

The Camp Fire Girls. — The Camp Fire Girls is an order 
similar in every way to the Boy Scouts and of still more 
recent origin. It is also offering to girls just what they have 
always wanted to do, and it also requires the presence of an 
adult, the Guardian of the Camp Fire. Every encouragement 
is given to the girls to go on walks, to camp out, to learn folk- 
dances, to swim, etc. It appeals to the romance in girl nature 
much as scouting appeals to the love of adventure in the 
boy nature. The Camp Fire Girls have had a marvellous 
development all over the country, as they have deserved 
to have. The training which they are giving for the life of 
woman is far more fundamental than that of the school. 
The same limitations apply to the Girls as to the Boy Scouts. 
It is almost or quite impossible at present to find " Guardians 
of the Camp Fire" in most country sections. Hence the order 
is little organized there. The rural village is the best place 
for them, as all the conditions are there favorable. I believe 
that the Camp Fire Girls also richly deserve a portion of the 
school time. The Camp Fire Girls receive honors for swim- 
ming and athletics. They take long walks and camp out. 
They must sleep with their windows open, and learn to live 
the open-air life. 



PLAY AND RECREATION AT THE RURAL SCHOOL 447 

Saturday Half-Holiday in the Country. — During a large 
part of the year the one well-nigh impassable barrier to all 
social and recreational developments in the country is the 
lack of time. Farm people cannot work twelve and fourteen 
hours a day for six days a week and have left either the time 
or the energy with which to play. Since they are isolated in 
their work, it is far more important that farm people should 
have some time and place where they can get together than 
it is for city people to have a half-holiday or a social centre. 
Without the Saturday half-holiday it is going to be nearly or 
quite impossible to hold the boys and girls and the hired men 
on the farms. The half-holiday is essential to the welfare of 
the country both socially and intellectually. The work of 
the farm is mostly solitary. It furnishes abundant opportu- 
nities to think. Farmers as a class are apt to l^e dignified and 
substantial people, whose independence and self-respect have 
been among the chief assets of the republic. These qualities 
have been developed in the silent and thoughtful work of the 
fields. Such work has often been highly educational, but 
that can only be when the mind takes up from time to time 
new thoughts to be worked over in the fields, as the cow chews 
her cud in the evening. If the mind does not have new ex- 
periences to elaborate, this time in the fields is apt to be 
largely lost to culture. 

Liberty H. Bailey says: "The Saturday half -holiday is com- 
ing in the country and coming fast." I have found it fairly 
common in parts of the Northwest, but there are many sec- 
tions of the country where it is still almost unknown. If there 
may be tennis-grounds and ball-fields and a picnic-grove at 
the consolidated or township school, and the community may 
meet there on Saturday afternoons during six months of the 
year, it will do more to solve the problem of rural life than 
anything else that I know. Here the boys might play baseball 
or practise scouting. The girls might play volley-ball or cro- 
quet or tennis, or have their Camp Fire. The little children 
could play their games, and the parents could have their picnic 



44^ EDUCATIONAL HYGIENE 

and social time. The teacher of agriculture might well give 
a lesson or demonstration to the adults at this time, or the 
farmers might drive to a neighboring farm where some in- 
teresting crop was being raised. I find that they are using 
the tree claims for these Saturday-afternoon picnics in parts 
of North Dakota. 

The Social Centre. — ^A rapid development of rural social 
centres is now going on in Minnesota and Wisconsin. In 
other sections the movement is less prominent, but there are 
beginnings throughout the country. Undoubtedly the social 
centre is more needed in^the country than it is in the city, 
because it is the country that most of all lacks social op- 
portunity. The social centre, however, belongs more to the 
social and educational side of life than the physical in the 
country. It has far more to do with mental hygiene than it 
has to do with physical hygiene or physical training. How- 
ever, many of the new township high schools and agricultural 
schools and consolidated schools have gymnasiums, and these 
are being used more or less in the evenings for basket-ball, 
volley-ball, and folk-dancing. There is an abimdance of 
time for the older boys and girls to take part in these activ- 
ities during the long winter evenings in the country, and it is 
to be hoped that a gymnasium will be a part of the equip- 
ment of all new consolidated schools as it already is of very 
many, and that it may be fully used by night as well as by 
day. If the principal of this consolidated school may now 
receive a small extra compensation as the director of the 
social centre and as Scout Master for the boys, almost any- 
thing is possible in the country community. 



